Incident, injury, trauma and illness record

• Service Name

  Select

• Completed on

  Date

• Prepared by

Details of person completing this record

• Name:

• Position/role:

• Date and time record was made

  Date

• Signature:

  Sign

Child Details

• Child’s full name:

• Date of birth:

  Date

• Gender

  Male

  Female

• Age:

Incident Details

• Time:

  Date

• Incident date:

  Date

• Location/ Room

• Name of witness:

• Date:

  Date

• Witness signature:

  Sign

• General activity at the time of incident/injury/trauma/illness:

• Cause of injury/trauma:

• Circumstances surrounding any illness, including apparent symptoms:

• Circumstances if child appeared to be missing or otherwise unaccounted for (incl duration, who found child etc):

• Circumstances if child appeared to have been taken or removed from service or was locked in/out of service (incl who took the child, duration):

Nature of injury/trauma/illness:

• Abrasion / Scrape

  Yes

  No

  N/A

• Allergic reaction (not anaphylaxis

  Yes

  No

  N/A

• Amputation Anaphylaxis

  Yes

  No

  N/A

• Asthma / respiratory

  Yes

  No

  N/A

• Bite wound/Bruise

  Yes

  No

  N/A

• Broken bone / fracture / dislocation

  Yes

  No

  N/A

• Burn / sunburn

  Yes

  No

  N/A

• Choking

  Yes

  No

  N/A

• Concussion

  Yes

  No

  N/A

• Crush / jam

  Yes

  No

  N/A

• Cut / open wound

  Yes

  No

  N/A

• Drowning (non-fatal)

  Yes

  No

  N/A

• Electric shock

  Yes

  No

  N/A

• Eye injury

  Yes

  No

  N/A

• Infectious disease

  Yes

  No

  N/A

• High temperature

  Yes

  No

  N/A

• Ingestion / inhalation / insertion

  Yes

  No

  N/A

• Internal injury / Infection

  Yes

  No

  N/A

• Poisoning

  Yes

  No

  N/A

• Rash

  Yes

  No

  N/A

• Respiratory

  Yes

  No

  N/A

• Seizure /unconscious/ convulsion

  Yes

  No

  N/A

• Sprain / swelling

  Yes

  No

  N/A

• Stabbing / piercing

  Yes

  No

  N/A

• Tooth

  Yes

  No

  N/A

• Venomous bite/sting

  Yes

  No

  N/A

• Other (please specify)

• Details of action taken (including first aid, administration of medication etc):

• Did emergency services attend?:

  Yes

  No

• Was medical attention sought from a registered practitioner / hospital?:

  Yes

  No

• If yes to either of the above, provide details:

• Have any steps been taken to prevent or minimise this type of incident in the future?:

Notifications (including attempted notifications)

• Parent/guardian name

• Date

  Date

• Time

  Date

• Director/educator/coordinator:

  Yes

  No

• Date

  Date

• Time

  Date

• Other agency (if applicable):

• Date:

  Date

• Time:

  Date

Regulatory authority (if applicable):

• Time:

  Date

• Date:

  Date

Parental Acknowledgement

• Name of parent/guardian notified of my child’s incident/injury/trauma/illness

• Date:

  Date

• Signature:

  Sign

• Additional notes: