Injury or Health and Safety Incident Reporting Form
This form is designed to collect information that occurs when an accident or near miss occurs either on the School grounds or on a School activity that may involve staff, students or members of our community.
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Date of incident *
Time of Incident *
Time
:
Location the incident occurred *
Specific detail of location of incident *
Name of person completing this form *
Name of person affected *
Description of incident *
Details of injury *
Required
What action was taken *
Required
Additional action comments *
Damage to property (if any)
Please describe the nature of any hazard that may need to be addressed in the future (location, possible mitigation measures)
What do you think is the likelihood of this incident/ injury occurring again? *
How would you rate the severity of this incident? *
See image below for descriptions
Incident Severity Scale
Ignore the Department of Labour (DOL) and National Incident Database references
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