Incident Report

Incident Report

This form should be used for incidents that happen during class or work time. You will need to use your judgment as to assess the seriousness of the incident. It may be appropriate to immediately call your manager or Cathy before submitting this form, particularly if you are concerned for a student's safety or your own safety. Incidents can be stressful and sometimes traumatic, it is important you reach out if you feel you need support after an incident.
Program Coordinator*
Manager*
Name of person completing the report*
This will usually be the class teacher
Email*
Please insert your Speak Up email address
Class details/location of incident*
Venue (eg. Red Hill studio), Program (eg. Storytellers), Teacher (eg. Miss Olivia)
Teacher mentor
Insert the name of your teacher mentor, if you are a teacher mentor leave this field blank
Date of incident*

MonthDayYear
Date
Time of incident*

Hour Minutes

AM/PM Option
People involved*
Include any students, parents, school staff or Speak Up staff that were involved in the incident
Description of Incident

Please include as much detail as possible
Summary of events prior*
What were the events leading up to the incident?
Description of incident*
Immediate action taken*
What did you do in the moment to mitigate risk?
Follow Up

What can we do going forward to ensure the risk of this happening again is minimised?
Suggested follow up*
Have you addressed this incident with the studio yet?*

No, I am using this report to notify the studioI have already discussed it with the program coordinator, my manager or Cathy
What can Speak Up do to support you and ensure you are okay after this incident?*

I would like to chat with my managerI would like to speak with the CathyI would like to speak with a psychologist or counsellorI don't need any further support
Should be Empty:

Incident Report

Description of Incident

Follow Up