Incident Report Details
Please fill in the form below.
Venue Incident Occurred
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Breakfast at Stephanies, Southern Cross Circuit
Orion Lagoon, 155 Southern Cross Crt
Person Completing Report
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First Name
Last Name
Person Completing Report Email
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Please enter the venue email above - not personal
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Person Injured
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First Name
Last Name
Sex
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Female
Date of Birth
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Phone Number
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-
Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State
Zip Code
If Under 18 Parent/Guardians
First Name
Last Name
Phone Number
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Area Code
Phone Number
Is the patient
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Member
Casual Guest
Employee
Contractor
Other
Upload Photo of area - include any relevant signs, safety warnings, hazards that caused the incident etc.
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The Incident
The incident was
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Injury
Alleged Assult
Alleged Theft
Dangerous Event
WHS Incident
Other
If injury please state type of injury and bodily location
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Description of incident - Detailed description. Include time, how the incident occurred and factors that may have contributed.
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Location inside venue - give as much detail as possible
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Workplace Health & Safety Incident
Was the correct PPE being worn
Yes
No
If Yes, describe in detail what was being worn/used
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The Treatment / Response
Explain in detail the treatment given to the patient.
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Include staff involved, public involved, pool closures, etc.
Did staff follow DRSABCD?
Yes
No
Was Oxygen Administered?
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Yes
No
Therapy
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Was the emergency services called?
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Police
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Manager
Have you notified general manager?
Yes
No
Time Notified
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Council Notified
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Submit
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