Red Book: Accidental Injury Report

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

Date

Hour MinutesAM/PM Option

The individual impacted by this injury (one form for each individual) was a

Other

Name of Individual impacted by injury

First NameLast Name

Contact details of individual who was injured (address, cell & email) if not staff

Were there witnesses to this injury?

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. Staff tripped, falling down the stairs):

Assess the severity of the injury to the person/people involved

Were there any 'lemons' surrounding this event? (ie causative factors that could have been avoided)

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?

Describe the hazard

Cause of Injury

Injury Type

Body Parts Affected

Describe the injury and treatment or assessment (if applicable)

Environment of incident/injury

Indoors: Which room of the house?

Outdoors: Describe (paddock, beach, road, cafe, etc.)

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?

Photo/Document Upload

Did injury require staff to stand down temporarily or permanently from programme/work?

Staff member is/unable to participate in programme/work for (best guess) hours/days/weeks .

Expected recovery time is (best guess)Number hours/days/weeks/months .

Recommendations by staff member?

Would you like to have a debrief with an RLNZ staff member or to get additional support? If you select yes, we will arrange a formal debrief for you. Please contact the on-call person if you need immediate support.

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

First NameLast Name

Rows	Action Required from Incident/Accident i.e. fix hazard,	Who is responsible	Date Completed
1
2
3
4

Red Book: Staff Accident/Injuries Report

Injury Details

Environmental Factors

Effects of Injury (if client/staff)

Staff Injury/Accident Review - Management to Complete