INJURY / ILLNESS DETAILS SUMMARY

  • Date and Time of Incident

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

1. INJURED PESON'S DETAILS

  • INJURED PERSON.

  • Full Name:

  • Student ID (if known)

  • Address:

  • Suburb:

  • Post Code:

  • Phone:

  • Why on school property:

  • Association with school:

2. REPORTING PERSON OR FIRST AID ATTENDANT

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

  • 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

5. INCIDENT INFORMATION

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

  • CAUSE - What caused he injury?

  • SEVERITY

  • TREATMENT REQUIRED

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

  • If first aid - what first aid was provided?

6. INJURY / ILLNESS DETAILS

  • Injury / Illness

  • Location on the Body

  • Sign - Reporting person or First Aid attendant

  • Sign - Injured Person

7. EMERGENCY CONTACT DETAILS

  • Has the injured persons emergency contact been notified? If not, why?

8.CAUSE OF ILLNESS/INJURY

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

  • If aggressor?

  • 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)

  • Associated equipment?

  • When was the hazard identified?

  • Who identified the hazard?

  • The potential for serious injury was:

  • Please take a photo if necessary:

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

  • Please select:

  • 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:

  • Select 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?

  • Possible legal actions?

  • Is this a 'notifiable' incident according to WH&S Act 2011?

  • Select 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

  • Stephen Wruck/Workplace Health and Safety officer

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