Child Incident Report Form

Person Impacted by incident:

First Name *

Last Name *

Incident Location/Activity *

Date of incident *

Time of incident *

Details/Description of incident *

How did you/we respond to the incident *

Was there equipment being used? If yes please fill out the rest of the form, if no go to the next section. *

Yes

Did the equipment being used contribute to the incident? *

Yes

Were there instructions on how to safely use the equipment or undertake the work? *

Yes

Was the person trained in the safe procedures for using the equipment? *

Yes

Did the person involved in the incident follow those instructions? *

Yes

What level of supervision and/or support was being provided when the incident occurred? *

Adequate

Minimal

None

Was emergency services called? *

Yes

Treatment Received

If the person affected went to the hospital, doctor or an ambulance was called please fill this section out

Was there initial medical advise sought? Medical advice is the provision of a formal professional opinion regarding what a specific individual should or should not do to restore or preserve health. Typically, medical advice involves giving a diagnosis and *

Yes

What advice/treatment was given? *

Was a medical certificate provided? *

Yes

Has the person affected been followed up with by staff to confirm the adequacy of treatment and recovery process? *

Yes

Action Taken

What immediate action was taken to avoid further injury? (stop work, incident debrief with workers) *

Who took this action: *

What Action has been taken to prevent future injury? (risk assessment undertaken and/or reviewed, work method practices changes etc) *

Parent or Guardian Contacted? *

Yes

Who did you talk to? Please detail the parent/guardian's name whom you communicated with. *

Who made this contact? *

Name of Person Filling out form: *

Your agreement

I hereby agree that, to the best of my knowledge, the provided information is true and accurate. *

Yes

First Name *

Last Name *

Date of Birth *