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Peel Bright Minds Incident Report Form
This is the incident report form for Peel Bright Minds Events, Trail Blazers and Junior Trail Blazers.
Please send email of completed form to info@peelbrightminds.com.au.
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* Indicates required question
Email
*
Your email
Name:
*
Your answer
Relationship to Peel Bright Minds?
*
Participant
Mentor
Visitor/Guest
Staff Member
Contractor
Date of Reporting
*
MM
/
DD
/
YYYY
Date of Incident
*
MM
/
DD
/
YYYY
Time of Incident
*
Time
:
AM
PM
Location
*
Your answer
Witnesses
*
Your answer
Reported to Who?
*
Michelle
John
Mentor
Full Incident Details -
What happened, or in the care of a near miss, what could have happened.
*
Your answer
Injury-
Nature of injury
*
Contusion/Crush
Laceration / Open Wound
Concussion
Burn
Superficial Issues
Sprain/Strain
Dislocation
Foreign Body
Fracture
Amputation
Internal Injury
Dermatitis
Personal Space / Mental Health
Child Safety Incident
Other:
Required
Location of Injury
*
Head/face
Hand/Fingers
Hip/Leg
Eye
Shoulder/Arms
Foot/Toes
Internal Organs
Trunk
Back
Mental Health / Personal Incident
Child Safety
Other:
Required
Result of Incident -
Not Required
Lost Time
Compensation Required
Other:
Treatment Recieved
*
First Aid
Doctor
Hospital
Exclusion/Inclusion Discussions
Other:
Damage
Damage to Buildings
Damage to Equipment
Damage to Vehicles
Other:
Contributing Factors to Incident
*
Your answer
Corrective Actions
-Immediate Actions
- Controls for preventing
*
Your answer
Date by which action is taken (one week from Today)?
*
MM
/
DD
/
YYYY
Name of Reporting Person:
*
Your answer
A copy of your responses will be emailed to the address you provided.
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