CRITICAL INCIDENT REPORT FORM
Part A. Incident Details:
Date of Incident
*
/
Day
/
Month
Year
Details:
*
Name of Student(s) who Involved:
Name of Staff(s) who Involved:
Part B. Action Taken:
Immediate actions taken when Critical Incident occurred:
*
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 occurring:
*
Yes
No
If Yes, please specify:
*
Have all staff / students affected been offered de-briefing / counselling sessions?
*
Yes
No
If yes, were these effective?
*
Yes
No
Part C. Follow Up:
Are there any changes / improvements required for our Critical Incident Policy?
*
Yes
No
If Yes, please specify:
*
Do any staff require any professional development to improve their skills following this critical incident?
*
Yes
No
Reporting Officer Name:
*
Officer Signature:
*
Clear
Date:
*
/
Day
/
Month
Year
Submit
Should be Empty:
