School Health and Safety Incident 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:

  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)

• 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

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)

• What was the primary hazard that caused the incident?

• 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

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 (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 WH&S Act 2011?

  Yes

  No

  N/A

• Select date

  Date

• 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:

• Lyndon Brewer/Business Manager

  Sign

• Stephen Wruck/Workplace Health and Safety officer

  Sign