MHS - School Health and Safety Accident Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• 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 PESON'S DETAILS

• INJURED PERSON.

  Staff Member

  School student

  Other person

• Full Name:

• Student ID (if known)

• Address:

• Suburb:

• Post Code:

• Phone:

• Why on school property:

• Association with school:

  Select Parent Public Visitor Volunteer Other

  • Parent
  • Public
  • Visitor
  • Volunteer
  • Other

2. REPORTING PERSON OR FIRST AID ATTENDANT

• Whether its 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)

3. LOCATION - WHERE THE INCIDENT OCCURRED

• Location:

• Phone Number (only if not staff)

• 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

5. INCIDENT INFORMATION

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

  Select Admin General Camp Chemicals/poisons Computer Work Curriculum Prac CurriculumTheory Playground Duty Equipment Usage Maintenance First Aid School Activity 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
  • Chemicals/poisons
  • Computer Work
  • Curriculum Prac
  • CurriculumTheory
  • Playground Duty
  • Equipment Usage
  • Maintenance
  • First Aid
  • School Activity
  • 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

  Minor (first aid/no time lost)

  Moderate (needs medical care)

  Serious (>4days away/perm injury/damage

  Fatal

• TREATMENT REQUIRED

  Nil

  First Aid (on site or ambulance officer)

  Doctor/out patients

  Hospitalisation (overnight stay or longer)

• If hospitalised - What is the name of the hospital ?

• If first aid - 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? If not, why?

  Yes

  No

  N/A

8.CAUSE OF ILLNESS/INJURY

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

  Yes

  No

  N/A

• If aggressor?

  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)

• Contributing Hazard Category (please select)

  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

  • 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?

  Date

• Who identified the hazard?

• The potential for serious injury was:

  High

  Low

• Please take a photo if necessary:

  Media

• Was there a primary hazard that caused the incident?

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 witness's please complete below:

• Signature of person completing audit:

  Sign

• Select date

  Date

• Name/Job Title

11. INCIDENT REFERRED TO WORKSAFE

• Referred to:

• To be completed by Nurse

• Follow up:

• Work cover claim?

  Yes

  No

  N/A

• Possible legal actions?

  Yes

  No

  N/A

• Is this a 'notifiable' incident according to H & S at Work Act 2015?

  Yes

  No

  N/A

• Select date

  Date

• Further actions: 1. Consult the School Business Manager on hazard details and the recommended control strategies. 2. place the original incident report on file at clinic after being signed by Business Manager. 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: