Information
-
Document No.
-
Incident Location
-
Conducted on
-
Prepared by
-
Signature
1. INJURED PESON'S DETAILS
-
INJURED PERSON.
-
Full Name:
-
Association with school:
- Staff
- Student
- Parent
- Public
- Visitor
- Volunteer
- Other
-
Student ID (if known)
-
Address:
-
Suburb:
-
Post Code:
-
Phone:
-
Emergency Contact Name (if known)
-
Emergency Contact Number (if known)
-
Why on school property:
2. REPORTING PERSON OR FIRST AID ATTENDANT
-
Whether its a staff or other person (if not staff please provide address and phone number )
-
Full Name:
-
Department:
-
Address (only if NOT staff)
-
Phone Number (only if NOT staff)
3. WHAT HAPPENED ?
-
Detailed description of incident ( consider the activity, what happened and why)
-
Provide more details if necessary:
-
Add/take picture of incident for record
4. INCIDENT INFORMATION
-
ACTIVITY - What was the activity at the time of the incident ?
- Admin General
- Assisting student
- Chemicals/poisons
- Computer Work
- Curriculum Prac
- CurriculumTheory
- Equipment Usage
- First Aid
- Lesson Prep/ Clean up
- Manual handling
- Maintenance
- Meeting
- Movement around school
- Non-school activity
- Restraining Student
- School Activity
- Unauthorized Activity
- Work General
- Other: (e.g bullying)
-
CAUSE - What caused he injury?
- Caught in/between
- Contact with
- Exposure to
- Object falling/flying
- Person falling
- Lifting/Handling
- Repetitive movement
- Running/jumping
- Stepping on /in
- Walking
- Struck by / or against
- Other
-
SEVERITY
- Minor (first aid/no time lost)
- Moderate (needs medical care)
- Serious (>4days away/perm injury/damage)
- Fatal
-
TREATMENT REQUIRED
- Nil
- First Aid (at incident location)
- First Aid (Sick Bay)
- First Aid (Ambulance Paramedic)
- Doctor/out patients
- Hospitalisation (overnight stay or longer)
-
If first aid - what first aid was provided?
-
If hospitalised - What is the name of the hospital ?
5. INJURY / ILLNESS DETAILS
-
Injury / Illness
- Ache/Pain
- Amputation
- Bite/Sting
- Bruise/crush
- Bump/Knock
- Burn/Scald
- Concussion
- Cumulative
- Cut/laceration
- Dislocation
- Fracture
- Headache
- Hearing Loss
- Infection/Disease
- Irritation/Allergy
- Nausea
- Poisoning
- Respiratory
- Sprain/strain
- Stress reaction
- Unconscious
- Unspecified
- Other
-
Location on the Body
- Ankle(s)
- Arm(s)
- Back lower
- Back upper
- Chest
- Ear(s)
- Elbow(s)
- Eye(s)
- Face
- Finger(s)
- Foot/feet
- Groin
- Head
- Hand(s)
- Hip(s)
- Internal
- Knee(s)
- Leg(s)
- Mouth
- Neck
- Nose
- Respiratory system
- Shoulder(s)
- Skin
- Stomach
- Stress related
- Toe(s)
- Tooth/teeth
- Wrist(s)
- Other:
-
Sign - Reporting person or First Aid attendant
-
Sign - Injured Person
6. EMERGENCY CONTACT DETAILS
-
Has the injured persons emergency contact been notified? If not, why?
7. CAUSE OF ILLNESS/INJURY
-
Was the injury/Illness caused by a confrontation or aggressive act?
-
If aggressor?
- Parent
- staff
- volunteer
- primary student
- secondary student
- Visitor
- other
-
Type of confrontation?
8. HAZARD INFORMATION/MANDATORY (if necessary seek assistance from school WHSO to determine the hazard)
-
What was the primary hazard that caused the incident?
-
Contributing Hazard Category (please select)
- Animal/insect
- Blood/body substance
- Building fixtures
- Electricity/Gas
- Electrical appliance
- Environmental factors
- Equipment (eg.Playground)
- Fire/explosion
- Floor/ground
- Foreign object (eg. splinter)
- Furnitue
- Machinery (fixed)
- Machinery (mobile)
- Non powered tool
- Person/people
- Stairs/steps
- Stress/trauma
- Sunburn/UV radiation
- Temperature
- Travel
- Radiation/arc flash
- Virus/disease
- Water/pool
- Working/learning environment
- other
-
Associated equipment?
-
When was the hazard identified?
-
Who identified the hazard?
-
The potential for serious injury was:
-
Please take a photo if necessary:
9. DETAILS OF WITNESS (if not staff please provide address and phone number below)
-
Please select:
-
Details if staff or student
-
Full Name:
-
Student ID (if known)
-
If there are other significant witness's please complete below:
-
Signature of person completing audit:
-
Select date
-
Name/Job Title
10. INCIDENT REFERRED (MANDATORY)
-
Referred to:
-
To be completed by either WHSO, Head of Dept
-
Follow up:
-
Work cover claim?
-
Possible legal actions?
-
Is this a 'notifiable' incident according to WH&S Act 2011?
FURTHER ACTIONS
-
1. Consult the School WHSO on hazard details and the recommended control strategies. 2. place the original incident report on file at clinic after being signed by WHSO. 3. Note: a copy of a student incident report may be provided to the student/parent/caregiver on request through the Principal. Details of other parties ( eg. Other students names) should be obscured.