Critical Incident Reporting Form

Critical Incident Reporting Form

(Use additional sheets where required and attach)
Type of critical incident (please tick)

Missing student Severe verbal or psychological aggression Death Serious injury Natural disaster Domestic violence Sexual assault Drug or alcohol abuse Other
Details of Critical Incident
Date:

Day Month Year
Date
Hour Minutes AM/PM Option
Location:
Person(s) Involved (Including Witnesses)

Type a question

Name

Address

Contact Details

Description of Critical Incident
Description of Injury (if applicable)
Description of Damage (if applicable)
Reported to Police?

Yes No
Did any other emergency service attend?
If yes, attach copy of report

Cancel of
Reported By:
Date

Day Month Year
Date
Signature:

Clear
Details of action taken by Critical Response Team Member:
Were these actions effective in dealing with the Critical Incident?

Yes No
Are there any preventative measures that can put in place to prevent another similar Critical Incident

Yes No
If yes, please detail
Have all staff / students affected been offered de-briefing / counselling sessions?

Yes No
If yes, were these effective?

Yes No
Recommended follow up action:
Signature

Clear
Date

Day Month Year
Date
WH&S recommended action:
Signature

Clear
Date

Day Month Year
Date
Media response (if applicable):
Follow Up
Are there any changes / improvements required for our Critical Incident Policy?

Yes No
If yes, please details
Are there any changes / improvements required for our Critical Incident Policy?

Yes No
Chief Executive Officer:
Signature:

Clear
Date:

Day Month Year
Date
Should be Empty:

Details of Critical Incident