Injury Report Form

• Conducted on

  Date

• Prepared by

• Location
  Address

• Injury Report ID

• Date and Time of Incident

  Date

• Name of Injured Person

• Name of Employee Reporting the Incident

• Venue
  Address

• Area

  Select 50m Pool 25m Pool Program Pool Leisure Pool Spa Gym Changing Rooms Other

  • 50m Pool
  • 25m Pool
  • Program Pool
  • Leisure Pool
  • Spa
  • Gym
  • Changing Rooms
  • Other

• Please specify

• Please list

• Please describe the incident location in detail

• Please include a photo of the incident location (where possible)

  Media

• Mode of Injury

  Select Assault Collission Entrapment Exposure Fall Ingestion Lifting, Pushing or Pulling Not specified Unruly Behaviour Slips Trips Other

  • Assault
  • Collission
  • Entrapment
  • Exposure
  • Fall
  • Ingestion
  • Lifting, Pushing or Pulling
  • Not specified
  • Unruly Behaviour
  • Slips
  • Trips
  • Other

• Type of Injury

  Select Respiratory Distress Bleeding Bruising / Swelling Burns Cardiac Distress Disorientation / Dizziness / Fainting Electric Shock Fracture Illness Irritation Laceration Loss of consciousness Not specified Pain Puncture Seizure Sprain Strain Other

  • Respiratory Distress
  • Bleeding
  • Bruising / Swelling
  • Burns
  • Cardiac Distress
  • Disorientation / Dizziness / Fainting
  • Electric Shock
  • Fracture
  • Illness
  • Irritation
  • Laceration
  • Loss of consciousness
  • Not specified
  • Pain
  • Puncture
  • Seizure
  • Sprain
  • Strain
  • Other

• Activity prior to injury

  Select Group Exercise Learn to Swim Recreation Squads Training Course Work Duties Other

  • Group Exercise
  • Learn to Swim
  • Recreation
  • Squads
  • Training Course
  • Work Duties
  • Other

• Were emergency services called to respond to the incident?

  Yes

  No

• Service Type

  Police

  Fire

  Ambulance

  Other

• If other, list

• Time of Call

  Date

• Called By

• Time of Arrival

  Date

• Officer in Charge (If Known)

• Event Number

• Contact Number

Injured Person

• Name

• Date of Birth

  Date

• Phone

• Email

• Address

• Suburb

• State

  Select New South Wales Australian Capital Territory Northern Territory Queensland South Australia Tasmania Victoria Western Australia

  • New South Wales
  • Australian Capital Territory
  • Northern Territory
  • Queensland
  • South Australia
  • Tasmania
  • Victoria
  • Western Australia

• Postcode

• Is the person involved a minor (under 18)?

  Yes

  No

• Guardian Name

• Phone

• Email

• Address

• Suburb

• State

  Select New South Wales Australian Capital Territory Northern Territory Queensland South Australia Tasmania Victoria Western Australia

  • New South Wales
  • Australian Capital Territory
  • Northern Territory
  • Queensland
  • South Australia
  • Tasmania
  • Victoria
  • Western Australia

• Postcode

Witnesses

• Name

• Type of Witness

  Employee

  Contractor

  Visitor

  Guest

  Other

• Date of Birth

  Date

• Phone

• Email

• Address

• Suburb

• State

  Select New South Wales Australian Capital Territory Northern Territory Queensland South Australia Tasmania Victoria Western Australia

  • New South Wales
  • Australian Capital Territory
  • Northern Territory
  • Queensland
  • South Australia
  • Tasmania
  • Victoria
  • Western Australia

• Postcode

Incident Responders

• Name

• Responder Type

  Employee

  Contractor

  Visitor

  Guest

  Other

• Phone

• Email

• Address

• Suburb

• State

  Select New South Wales Australian Capital Territory Northern Territory Queensland South Australia Tasmania Victoria Western Australia

  • New South Wales
  • Australian Capital Territory
  • Northern Territory
  • Queensland
  • South Australia
  • Tasmania
  • Victoria
  • Western Australia

• Postcode

• Did the injured person require any of the following?

  CPR / Resuscitation

  Defibrillation

  Spinal Immobilisation

  Not applicable

• Injury Classification

  Fatality

  Lost Time Injury

  Major Injury

  Minor Injury

  Near Miss

• Which part/s of the body was injured?

  Select Eye Ear Face Head Neck Chest Abdomen Back Shoulder, Elbow or Arm Hands, Fingers or Wrist Hip, Leg or Knee Foot, Toe or Ankle Other

  • Eye
  • Ear
  • Face
  • Head
  • Neck
  • Chest
  • Abdomen
  • Back
  • Shoulder, Elbow or Arm
  • Hands, Fingers or Wrist
  • Hip, Leg or Knee
  • Foot, Toe or Ankle
  • Other

• Which side/s of the body were injured?

  Select Left Right Front Back

  • Left
  • Right
  • Front
  • Back

• What was the nature of the injury? Describe in detail

• Describe fully how the accident happened?

• Was equipment or tools being used?

  Yes

  No

• Explain what equipment, tools were being used?

• Did the injured person give consent for First Aid treatment?

  Yes

  No

  Unable to consent

• Describe why the casualty was unable to consent

• Treating First Aid Officer

• Time Treatment Commenced

  Date

Treatment

• What type of treatment was provided?

  Select CPR / Resuscitation Defibrillation Oxygen Therapy Management of bleeding Medication Administered R.I.C.E.R Spinal Immobilisation Other

  • CPR / Resuscitation
  • Defibrillation
  • Oxygen Therapy
  • Management of bleeding
  • Medication Administered
  • R.I.C.E.R
  • Spinal Immobilisation
  • Other

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?

  Yes

  No

• Was the patient conscious?

  Yes

  No

• Did you send for assistance/help?

  Yes

  No

• Was the airway clear?

  Yes

  No

• Was normal breathing present?

  Yes

  No

• Was CPR commenced?

  Yes

  No

• Did the patient regurgitate at any time?

  Yes

  No

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

  Yes

  No

• Was the patient on any medication for any condition?

  Yes

  No

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

  Yes

  No

CPR / Resuscitation

• Who performed CPR / resusctiation?

• During resuscitation, which techniques were used:

  Select Mouth to Mouth Mouth to Mask Oxygen Supplemented (Mouth to Mask with Oxygen) Oxygen Resuscitation (BVM)

  • Mouth to Mouth
  • Mouth to Mask
  • Oxygen Supplemented (Mouth to Mask with Oxygen)
  • Oxygen Resuscitation (BVM)

• Time CPR / Resuscitation commenced

  Date

• Time CPR / Resuscitation concluded or transferred to emergency personnel

  Date

• Was there any difficulty in establishing or maintain an airway?

  Yes

  No

• If ‘Yes’, was it because of:

  Select Head tilt Clenched or damaged jaw Trauma to face and mouth Obstruction (teeth etc) Other

  • Head tilt
  • Clenched or damaged jaw
  • Trauma to face and mouth
  • Obstruction (teeth etc)
  • Other

• If other, please list

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

  Yes

  No

• If ‘No’, was it because of:

  Blocked airway

  Chest trauma

  Other

• 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?

  Yes

  No

  Don't know

• If yes, please describe

• Did the patient recover before emergency medical assistance arrived?

  Yes

  No

• Please provide any additional comments

Defibrillation

• Was a functioning defibrillator available?

  Yes

  No

• Was a functioning defibrillator used?

  Yes

  No

• Has data from the defibrillator been retained for investigation?

  Yes

  No

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

  Yes

  No

  N/A

• Is there further medical treatment/referral required?

  Yes

  No

• Type of further treatment advised

• Reported By

• Signed

  Sign

• Shift Supervisor

• Signed

  Sign