Details

Date and Time of Incident

Name of Injured Person

Name of Employee Reporting the Incident

Venue
Area

Please specify

Please list

Please describe the incident location in detail

Please include a photo of the incident location (where possible)
Mode of Injury
Type of Injury
Activity prior to injury

Were emergency services called to respond to the incident?

Service Type

If other, list

Time of Call

Called By

Time of Arrival

Officer in Charge (If Known)

Event Number

Contact Number

Persons Involved

Injured Person

Name

Date of Birth

Phone

Email

Address

Suburb

State

Postcode

Is the person involved a minor (under 18)?

Guardian Name

Phone

Email

Address

Suburb

State

Postcode

Witnesses

Name

Type of Witness

Date of Birth

Phone

Email

Address

Suburb

State

Postcode

Incident Responders

Name

Responder Type

Phone

Email

Address

Suburb

State

Postcode

Injury Details

Did the injured person require any of the following?

Injury Classification

Which part/s of the body was injured?
Which side/s of the body were injured?

What was the nature of the injury? Describe in detail

Describe fully how the accident happened?

Was equipment or tools being used?

Explain what equipment, tools were being used?

First Aid

Did the injured person give consent for First Aid treatment?

Describe why the casualty was unable to consent

Treating First Aid Officer

Time Treatment Commenced
Treatment
What type of treatment was provided?
Oxygen Therapy

What flow rate was used for oxygen therapy?

What duration was each cycle of oxygen therapy?

How many total cycles of oxygen therapy were provided (if more than one)?

R.I.C.E.R

For how long was ice applied?

Number of cycles ice was applied?

DRSABCD

Describe your assessment of dangers

Did the patient respond verbally or physically?

Was the patient conscious?

Did you send for assistance/help?

Was the airway clear?

Was normal breathing present?

Was CPR commenced?

Did the patient regurgitate at any time?

Were any medical personnel in attendance at any time during treatment / resuscitation?

Was the patient on any medication for any condition?

Was the patient perceived to be under the influence of drugs or alcohol?

CPR / Resuscitation

Who performed CPR / resusctiation?

During resuscitation, which techniques were used:
Time CPR / Resuscitation commenced
Time CPR / Resuscitation concluded or transferred to emergency personnel

Was there any difficulty in establishing or maintain an airway?

If ‘Yes’, was it because of:

If other, please list

During resuscitation, did you observe rise and fall of the chest?

If ‘No’, was it because of:

If other, please list

How much time (in minutes) passed between learning of the incident to the first breath was administered?

Did the patient’s colour change during resuscitation?

If yes, please describe

Did the patient recover before emergency medical assistance arrived?

Please provide any additional comments

Defibrillation

Was a functioning defibrillator available?

Was a functioning defibrillator used?

Has data from the defibrillator been retained for investigation?

Bleeding

Provide details of treatment of bleeding

Medications

What type of medication was administered?

What was the dosage of medication?

Other Treatment

Describe any other treatment provided

Is there further medical treatment/referral required?

Type of further treatment advised

Sign-Off

Reported By

Signed

Shift Supervisor

Signed
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.