Details of Person Completing this form
Name
*
Position Role
*
Date Record was made
*
Time Record was made
*
Signature
Child Details
Child's Full Name
*
Child's Date of Birth
*
Child's Age
*
Gender
*
Male
Female
Incident, Injury, Trauma and Illness Details
Date
*
Time
*
Location of Incident Injury Trauma Illness
*
Name of persons who witnessed the Incident Injury Trauma Illness
*
Location of Service
*
Witness Signature
Date
-
Day
-
Month
Year
Date
Details of Incident Injury Trauma Illness
*
Circumstance leading to Incident Injury Trauma Illness including any apparent symptoms
*
Circumstance if child appeared to be missing or otherwise unaccounted for (incl. Duration, who found child, etc.)
*
Circumstance if child appeared to have been taken or removed from service or was locked in/out of service (include, who took the child, duration)
*
Nature of Incident/ Injury/ Trauma/ Illness
*
Abrasion / scrape
Allergic reaction (not anaphylaxis)
Amputation
Anaphylaxis
Asthma / respiratory
Bite wound
Bruise
Broken bone / fracture / dislocation
Burn / sunburn
Choking
Concussion
Crush / jam
Cut / open wound
Drowning (non-fatal)
Electric shock
Eye injury
Infectious disease (incl. gastrointestinal)
High temperature
Ingestion / inhalation / insertion
Internal injury / infection
Poisoning
Rash
Respiratory
Seizure / unconscious/ convulsion
Sprain / swelling
Stabbing / piercing
Tooth
Venomous bite / sting
Other
Other
Describe in detail affected body part
*
Did you submit actual photos of Incident/ Injury/ Trauma/ Illness
*
Yes
No
Upload Actual Incident/ Injury/ Trauma/ Illness Photos
*
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of
Action Taken
Details of action taken including first aid administration of medication etc
*
Did emergency services attend
*
Yes
No
Time emergency services contacted
*
Time emergency services arrived
*
Was medical attention sought from a registered practitioner / hospital?
*
Yes
No
If yes to either of the above, provide details
*
Have any steps been taken to prevent or minimise this type of incident in the future? If yes, provide details
*
Notification (including attempted notification)
1 - Parent/Guardian/Carer Name
*
Name of person who notified parent
*
Type of Notification
*
Date
Time
Signature
2 - Parent/Guardian/Carer Name
*
Name of person who notified parent
*
Time
Date
Signature
Type of Notification
*
Director / Educator / Coordinator Name
Date
Time
Lock Data
Yes
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Director Signature
Other Agency Name (if applicable)
Date
Time
Signature
Regulatory authority (if applicable)
Date
Time
Signature
Parental acknowledgement:
Parent Name
Last Name
I have been notified of my child’s
Incident
Injury
Trauma
Illness
Date
Signature
Additional notes
Submit
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