Red Book: Accidental Injury Report

Red Book: Accidental Injuries Report

Staff or Clients
Injuries are to be reported if they meet ANY of the below criteria:

1. Require medical attention over and above what is able to be provided from a basic first aid kit from RLNZ (eg. band aids, tweezers, antiseptic cream).

2. If the injury receives any medical assessment or treatment outside of RLNZ for example, a doctors surgery or A&E (for example, assessment for a concussion)

3. If the injury requires staff or client to miss more than one segment (2 hours) of programme due to the injury (i.e. burn from the stove and unable to attend duties, group or therapy as a result).

*Note: ANY injury is to be noted in the comms log.
Date and time of INJURY*

DayMonthYear
Date
Hour MinutesAM/PM Option
The individual impacted by this injury (one form for each individual) was a*

Staff memberClientOther
Name of Individual impacted by injury*

First NameLast Name
Client was on level:
Contact details of individual who was injured (address, cell & email) if not staff or client
Were there witnesses to this injury?

YesNo
Contact details (address, phone and email) of witness if they are not staff or clients
Describe what happened PRIOR to injury (eg. client was about to descend the stairs from the therapy rooms):
Describe the EVENT that created the injury (eg. Client tripped, falling down the stairs):
Assess the severity of the injury to the person/people involved

1 Minor2 Moderate3 Major4 Severe
Is this a reportable SAC event? (Refer to whiteboard)

NoYes - SAC 4Yes - SAC 3Yes - SAC 2Yes - SAC 1
Were there any 'lemons' surrounding this event? (ie causative factors that could have been avoided)

YesNo
Describe the lemons surrounding this event (eg. client was wearing socks):
Are there any new HAZARDS that have been identified as a result of this injury?

YesNoPotentially
Describe the hazard
Injury Details
Cause of Injury
Injury Type
Body Parts Affected
Describe the injury and treatment or assessment (if applicable)
Environmental Factors
Environment of incident/injury
Indoors: Which room of the house?
Outdoors: Describe (paddock, beach, road, cafe, etc.)
Weather at time of incident/injury
Were any of the following present and could be considered causative to the injury?
Are there photos or documents to upload of the incident/injury?

YesNo
Photo/Document Upload

Cancelof
Effects of Injury (if client/staff)
Did injury require client/staff to stand down temporarily or permanently from programme/work?
Client/staff was is/unable to participate in programme/work for (best guess) hours/days/weeks .
Expected recovery time is (best guess)Number hours/days/weeks/months .
Are clients next of kin required to be notified? (if incident severity is 'Moderate', 'Major', 'Severe' or if client is a minor, the answer is 'yes')?

YesNoUnsure
Recommendations by staff member?
Would you like to have a debrief with an RLNZ staff member or to get additional support?

YesNo
Name of Staff Member completing the above part of this form?*

First NameLast Name
Should be Empty:

Red Book: Accidental Injuries Report

Injury Details

Environmental Factors

Effects of Injury (if client/staff)