Monkey Bars Incident, Injury, Trauma & Illness Record

• Site conducted

  Select

• Child's Full Name

• Conducted on

  Date

• Prepared by

• Location
  Address

CHILD DETAILS

• Child’s full name

• Date of birth

  Date

• Age

• Gender

  Male

  Female

• Report for

  incident

  injury

  trauma

  illness

• Date and Time of incident/injury/trauma/illness

  Date

FORM DECLARATION

• I declare that this record has been completed as soon as possible and no later than 24 hours after any incident, injury, trauma or illness has transpired whilst the child is being educated and cared for by the Service.

DETAILS OF PERSON COMPLETING FORM

• Name and Signature

  Sign

• Position/role

• Date

  Date

• Time Record was completed

  Date

DETAILS OF PERSON WHO WITNESSED THE INCIDENT, INJURY OR TRAUMA

• Name and Signature of Witness

  Sign

• Position/role

• Due to privacy and confidentiality laws, do not identify the names of any other children involved in the incident/injury/trauma due. A separate form is required for each child involved in any incident, injury or trauma event

• NOTE: Educators are required to document any further changes to this record by writing the time and date next to any areas that have changed from the time and date listed above. The signature of the parent and the signature of the person making the changes must be recorded next to each change.

Child’s symptoms- circumstances surrounding child’s illness

• Details

• Time and onset of the illness

  Date
Temperature

• Temperature record

• Time temperature was taken

  Date

ACTION TAKEN

• Details of action taken (include first aid, administration of any medication)

• Were medical personnel contacted?

  Yes

  No

• Did emergency services attend?

  Yes

  No

• Was the child transported by ambulance?

  Yes

  No

• Does the illness require the child to be excluded from care?

  Yes

  No

• Does the illness require notification to the Health Department or other recognised authorities?

  Yes

  No

• Recommended minimum exclusion period

  Yes

  No

• Has the parent been informed of the exclusion period and medical clearance requirements?

  Yes

  No

• Complete the notification and parent acknowledgement below

• Circumstances leading to the incident, injury or trauma

• Date and Time

  Date

• Equipment/resources involved

• Location
  Address

• Circumstances if child appeared to be missing or otherwise unaccounted for (including duration of missing child and who/when the child was found)

• Circumstances if child appeared to have been taken from the service or was locked in/out of the service

• indicate part of body affected

  Drawing

• Select applicable

  Select Abrasions/Scrape Allergic reaction (not anaphylaxis) Bite Broken bone/fracture Bruise Burn/sunburn Choking Concussion Cut Electric shock Eye injury Infectious disease Rash Seizure (unconscious/convulsion) Sprain Swelling Tooth Venomous bite Other (please specify)

  • Abrasions/Scrape
  • Allergic reaction (not anaphylaxis)
  • Bite
  • Broken bone/fracture
  • Bruise
  • Burn/sunburn
  • Choking
  • Concussion
  • Cut
  • Electric shock
  • Eye injury
  • Infectious disease
  • Rash
  • Seizure (unconscious/convulsion)
  • Sprain
  • Swelling
  • Tooth
  • Venomous bite
  • Other (please specify)

• Specify Other

• Details of action taken (include first aid, administration of any medication)

  Yes

  No

• Were medical personnel contacted?

  Yes

  No

• Did emergency services attend?

  Yes

  No

• Was the child transported by ambulance?

  Yes

  No

• Does the illness require the child to be excluded from care?

  Yes

  No

• Does the illness/incident require notification to the Health Department or other recognised authorities?

  Yes

  No

• Recommended minimum exclusion period

  Yes

  No

• Has the parent been informed of the exclusion period and medical clearance requirements?

  Yes

  No

• (Including attempted notifications)

• Parent/guardian/emergency contact

• FULL NAME

• DATE AND TIME

• Successfully contacted

  Yes

  No

• Supervisor/ Responsible PersonS

• FULL NAME

• DATE AND TIME

• Successfully contacted

  Yes

  No

• Regulatory Authority Officer (if applicable)

• FULL NAME

• DATE AND TIME

• Successfully contacted

  Yes

  No

• Medical Authorities / Personnel

• FULL NAME

• DATE AND TIME

• Successfully contacted

  Yes

  No

• Has a medical certificate been provided, stating the child is fit to return to the Service?

  Yes

  No

• Has the medical certificate been submitted into the child’s file?

  Yes

  No

• I (name of parent/guardian) have been notified of my child’s incident, injury, trauma or illness.

• Parent Signature

  Sign

• Date

  Date

• Phone number

• Additional notes/comments

• Nominated Supervisor Name and Signature

  Sign

• Date and Time

  Date

• ** The above is considered best practice- not mandated.