Marsh - School Health and Safety Incident Report

• Facility Name

• Prepared by

• Date

  Date
• Location
  Address

General

• Document No.

• Personnel

INJURY / ILLNESS DETAILS SUMMARY

• Date and Time of Incident

  Date

• Was any person injured or ill as a result of this incident: <br>(If 'No' - only complete form if incident was a dangerous event)

  Yes

  No

  N/A

1. INJURED PERSON'S DETAILS

• Injured Person

  Staff Member

  School student

  Other person

• Full Name

• Student ID (if known)

• Address

• Suburb

• Post Code

• Phone

• Reason for presence on school property

• Association with school

  Select Student Staff Parent Public Visitor Volunteer Other

  • Student
  • Staff
  • Parent
  • Public
  • Visitor
  • Volunteer
  • Other

• If the incident caused a leave of absence, indicate how many days

• The incident must be reported to HSE

2. REPORTING PERSON OR FIRST AID ATTENDANT

• Whether it's a staff or other person (if not staff please provide address and phone number )

  Staff Member

  Other Person

• Full Name

• Department

• Address (only if not staff)

• Phone Number (only if not staff)

3. LOCATION - WHERE THE INCIDENT OCCURRED

• Location

• Name of the facility (if known)

4. 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

  Media

• Add witness statement, if available

• Add risk assessments for the activity being undertaken and other correspondence

5. INCIDENT INFORMATION

• ACTIVITY - What was the activity at the time of the incident ?

  Select Admin General Camp Contact with chemicals in class (i.e. Science Lab) Computer Work Curriculum Prac CurriculumTheory Playground Duty Equipment Usage Maintenance First Aid Class Activity (i.e. Cooking, Woodworking, Electronics etc) Assisting student Listing/Manual handling Meeting Movement around school Grounds care Non-school activity Camp Play- supervised Play - unsupervised Lesson Prep/ Clean up Restraining Student Sport/ Co-curricular Travel To/From school Excursion/Trip Tuckshop Unauthorized Activity Work General Other: (e.g bullying)

  • Admin General
  • Camp
  • Contact with chemicals in class (i.e. Science Lab)
  • Computer Work
  • Curriculum Prac
  • CurriculumTheory
  • Playground Duty
  • Equipment Usage
  • Maintenance
  • First Aid
  • Class Activity (i.e. Cooking, Woodworking, Electronics etc)
  • Assisting student
  • Listing/Manual handling
  • Meeting
  • Movement around school
  • Grounds care
  • Non-school activity
  • Camp
  • Play- supervised
  • Play - unsupervised
  • Lesson Prep/ Clean up
  • Restraining Student
  • Sport/ Co-curricular
  • Travel To/From school
  • Excursion/Trip
  • Tuckshop
  • Unauthorized Activity
  • Work General
  • Other: (e.g bullying)

• CAUSE - What caused he injury?

  Select 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

  • 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

  Select Minor (first aid/no time lost) Moderate (needs medical care) Serious (>4days away/perm injury/damage Fatal

  • Minor (first aid/no time lost)
  • Moderate (needs medical care)
  • Serious (>4days away/perm injury/damage
  • Fatal

• TREATMENT REQUIRED

  Select Nil First Aid (on site or ambulance officer) Doctor/out patients Hospitalisation (overnight stay or longer)

  • Nil
  • First Aid (on site or ambulance officer)
  • Doctor/out patients
  • Hospitalisation (overnight stay or longer)

• What is the name of the hospital ?

• What first aid was provided?

6. INJURY / ILLNESS DETAILS

• Injury / Illness

  Select 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

  • 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

  Select Head Face Eye(s) Nose Mouth Tooth/teeth Ear(s) Neck Back upper Back lower Chest Shoulder(s) Arm Elbow(s) Wrist(s) Hand(s) Finger(s) Stomach Hip(s) Groin Leg(s) Knee(s) Ankle(s) Foot/feet Toe(s) Skin Respiratory system Internal Stress related Other:

  • Head
  • Face
  • Eye(s)
  • Nose
  • Mouth
  • Tooth/teeth
  • Ear(s)
  • Neck
  • Back upper
  • Back lower
  • Chest
  • Shoulder(s)
  • Arm
  • Elbow(s)
  • Wrist(s)
  • Hand(s)
  • Finger(s)
  • Stomach
  • Hip(s)
  • Groin
  • Leg(s)
  • Knee(s)
  • Ankle(s)
  • Foot/feet
  • Toe(s)
  • Skin
  • Respiratory system
  • Internal
  • Stress related
  • Other:

• Sign - Reporting person or First Aid attendant

  Sign

• Sign - Injured Person

  Sign

7. EMERGENCY CONTACT DETAILS

• Has the injured persons emergency contact been notified?

  Yes

  No

• If not, why?

8.CAUSE OF ILLNESS/INJURY

• Was the injury/Illness caused by a confrontation or aggressive act?

  Yes

  No

  N/A

• Has an aggressor be identified?

  Select Parent Staff Volunteer Primary student Secondary student Other

  • Parent
  • Staff
  • Volunteer
  • Primary student
  • Secondary student
  • Other

• Type of confrontation?

9. 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)

  Select Animal/insect Blood/body substance Building fixtures Chemical substance Electricity/Gas Electrical appliance Environmental factors Equipment (eg.Playground) Fire/explosion Floor/ground Foreign object (eg. splinter) Furniture 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

  • Animal/insect
  • Blood/body substance
  • Building fixtures
  • Chemical substance
  • Electricity/Gas
  • Electrical appliance
  • Environmental factors
  • Equipment (eg.Playground)
  • Fire/explosion
  • Floor/ground
  • Foreign object (eg. splinter)
  • Furniture
  • 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?

  Date

• Who identified the hazard?

• The potential for serious injury was

  High

  Low

• Please take a photo if necessary

  Media
10. DETAILS OF WITNESS (if not staff please provide address and phone number below)

• Please select:

  Staff member

  School student/Class

  Other person eg. Volunteer

• Details if staff or student

• Full Name

• Student ID (if known)

• If there are other significant witnesses please complete below

• Signature of person completing audit:

  Sign

• Date and Time

  Date

11. INCIDENT REFERRED (MANDATORY)

• Referred to:

• To be completed by either WHSO, Head of Behavior Management, Head of Maintenance

• Follow up:

• Work cover claim?

  Yes

  No

  N/A

• Possible legal actions?

  Yes

  No

  N/A

• Is this a 'notifiable' incident according to RIDDOR?

  Yes

  No

  N/A

• https://www.hse.gov.uk/riddor/
  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.

Non staff contact details

• Name:

• Address:

• Contact details:

• Signature

  Sign