Incident Report
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1
2
3INCIDENT REPORT
1.
Staff
Teacher
Organiser
Volunteer
Student
2.
Incident Category
Notification – Nil Injury
Dancing Related Illness
Fatality
Near Miss
Dancing Related Injury
Dangerous Event
Serious Bodily Injury
Electrical Incident
Security
3.
Personal Data
Surname
Date of Birth
Given Names
Gender
4.
Affiliation Data Category of Person
Paid/Volunteer
Person in charge of location
Telephone
Starting date and time
Intended finishing date and time
5.
Incident Details
)
(if insufficient room attach details/diagram/drawing
Location of Incident
(exactly where did the incident occur)
Date and time of the Incident
Date and Time Reported
Reported to Name
Position
Witness Name
Witness Name
What happened unexpectedly?
How exactly did/could the illness, injury or damage happen?
Experience in task
years
Injury/Illness
Head
General
Slip or trip
Eye
Computer/keyboard use
Fall from height/ same
(classification)
level
Ear
Administration
Brain injury/ concussion
Hitting moving/
Mouth
Driving/riding
Fracture
stationary object
Nose
Walking/running
Wound/laceration/
Hit by moving object
Face
Dancing
contusion/bruising
Assault by person(s)
Neck
General Duties
Amputation
Tendon/muscular stress
Back: upper/lower
Manual Handling
Sharp/needle puncture
Repetitive movement
Chest
Lifting/carrying
Internal injury
Vehicle accident
Abdomen/pelvic
Push/pulling
Burn
Harassment/ bullying
Shoulder
Twisting/bending
Nerve/spinal injury
Work pressure
Upper arm/elbow/
Reaching
Joint/ligament/
Exposure/contact with:
Forearm
Repeated Movements
muscle/tendon injury
Mental stress factors
Wrist
Machinery/ equipment
Ear/eye/nose injury
Heat/cold
Hand/fingers/
Poisoning
Thumb
Sound/pressure
Electrocution
Hip
Chemical/substance
Musculoskeletal disease
Upper/low leg
Radiation
Mental illness/stress
Knee
Electricity
Digestive system
Ankle/foot/toe
Animal/insect
Skin disease/ dermatitis
Circulatory/
Biological factors
Nervous system/ sense
respiratory/digestive/
Other:
organ diseases
nervous system
Respiratory disease
Psychological
Heart/circulatory
Nil
Infection/virus
Cancer/melanoma
Nil injury
Action at the Time
What Happened
Prime Cause
(task involved)
(mechanism)
(agency)
Body Part Affected
(location)
Workers’ Compensation
6.
- Will a Work Cover claim be submitted for this incident? Yes No Unsure
Completed by
7.
Signature
Name
Date
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