Incident Reporting Tool

LSU Incident Reporting Tool
If this incident occurred during an AU Club Activity outside of the LSU Building then please use the AU Accident Reporting Form
Reporters Name - Who is reporting the incident?*

First NameLast Name
Reporters Area of Work/Study (Please select ALL that apply)*

LSU Duty Manager/Security ManagerStudentLSU Permanent StaffLSU Casual StaffLSU Volunteer
Was this Incident a Near Miss?*

YesNo
Was this an Incident of Shoplifting or attempted Shoplifting?*

YesNo
Date & Time of Incident*

DayMonthYear
Date
Hour Minutes
Incident Location*
Detailed Description of Location (if required)
Incident Details (provide details of what occurred, don't include medical details in this section) *
What Actions were Taken as a Result of this Incident?
Relevant Cameras
Duty Managers Involved in the Incident (include the reporter if applicable)

Dan GallagherNathaniel OlsonGlen WatsonKieran HehirPeta JarvisEthan BaggottSimon CarterHarry Hughes-SlatteryEmily HallBen PerksBethryn Keysell-Fitzpatrick
Other Staff Members/Contractors Involved
Relevant Images (if you believe an image would provide better context to this report)

Cancelof
Did anyone require medical attention? (this includes first aid treatment or self administered first aid e.g. applying a plaster)

NoYes - 1 PersonYes - 2 PeopleYes - 3 People
- Is the patient?*
  
  A studentA member of casual staffA member of career staffA member of the publicOther
- Patient's Student ID Number*
- Patient's Name*
  
  First NameLast Name
- Patient's Date of Birth
  
  DayMonthYear
  Date
- Patient's Phone Number
  Please enter a valid phone number.
- Patient's Email
  example@example.com
- Patient's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Complaint*
- PRF Number
- Description of Injury & Treatment Given*
  For FREC3 and above this should be in the format PC,HxPC, O/A, O/E, Tx, Plan and should include Obs and Scores where relevant
- Further Care Pathway*
- Friend's Student ID Number*
- Friend's Name*
  
  First NameLast Name
- Ambulance Number
- Treatment Provided By*
  
  Nathaniel OlsonGlen WatsonKelly HopeMatthew MansfieldJames WallaceKyle RobinsonDan BarkerGary ParkinsonEddie KentOther
- Medic's Phone Number*
  Please enter a valid phone number.
- Medic's Email*
  example@example.com
- Is the patient?*
  
  A studentA member of casual staffA member of career staffA member of the publicOther
- Patient's Student ID Number*
- Patient's Name*
  
  First NameLast Name
- Patient's Date of Birth
  
  DayMonthYear
  Date
- Patient's Phone Number
  Please enter a valid phone number.
- Patient's Email
  example@example.com
- Patient's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Complaint*
- PRF Number
- Description of Injury & Treatment Given*
  For FREC3 and above this should be in the format PC,HxPC, O/A, O/E, Tx, Plan and should include Obs and Scores where relevant
- Further Care Pathway*
- Friend's Student ID Number*
- Friend's Name*
  
  First NameLast Name
- Ambulance Number
- Treatment Provided By*
  
  Nathaniel OlsonGlen WatsonKelly HopeMatthew MansfieldJames WallaceKyle RobinsonDan BarkerGary ParkinsonEddie KentOther
- Medic's Phone Number*
  Please enter a valid phone number.
- Medic's Email*
  example@example.com
- Is the patient?*
  
  A studentA member of casual staffA member of career staffA member of the publicOther
- Patient's Student ID Number*
- Patient's Name*
  
  First NameLast Name
- Patient's Date of Birth
  
  DayMonthYear
  Date
- Patient's Phone Number
  Please enter a valid phone number.
- Patient's Email
  example@example.com
- Patient's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Complaint*
- PRF Number
- Description of Injury & Treatment Given*
  For FREC3 and above this should be in the format PC,HxPC, O/A, O/E, Tx, Plan and should include Obs and Scores where relevant
- Further Care Pathway*
- Friend's Student ID Number*
- Friend's Name*
  
  First NameLast Name
- Ambulance Number
- Treatment Provided By*
  
  Nathaniel OlsonGlen WatsonKelly HopeMatthew MansfieldJames WallaceKyle RobinsonDan BarkerGary ParkinsonEddie KentOther
- Medic's Phone Number*
  Please enter a valid phone number.
- Medic's Email*
  example@example.com
- Does anyone need to be disciplined as a result of this incident?
  
  NoYes - 1 PersonYes - 2 PeopleYes - 3 PeopleYes - 4 People
- Is this person?*
  
  A studentA member of casual staffA member of permanent staffA member of the publicOther
- Is this person a member of Casual Venue Staff?*
  
  YesNo
- ID Number*
- Name*
  
  First NameLast Name
- Does this require escalation to an executive officer?*
  
  YesNo
- Email of Ban Recipient*
  example@example.com
- Requested Ban End Date*
  
  DayMonthYear
  Date
  Hour Minutes
- Is this person?*
  
  A studentA member of casual staffA member of permanent staffA member of the publicOther
- Is this person a member of Casual Venue Staff?*
  
  YesNo
- ID Number*
- Name*
  
  First NameLast Name
- Does this require escalation to an executive officer?*
  
  YesNo
- Email of Ban Recipient*
  example@example.com
- Requested Ban End Date*
  
  DayMonthYear
  Date
  Hour Minutes
- Is this person?*
  
  A studentA member of casual staffA member of permanent staffA member of the publicOther
- Is this person a member of Casual Venue Staff?*
  
  YesNo
- ID Number*
- Name*
  
  First NameLast Name
- Does this require escalation to an executive officer?*
  
  YesNo
- Email of Ban Recipient*
  example@example.com
- Requested Ban End Date*
  
  DayMonthYear
  Date
  Hour Minutes
- Is this person?*
  
  A studentA member of casual staffA member of permanent staffA member of the publicOther
- Is this person a member of Casual Venue Staff?*
  
  YesNo
- ID Number*
- Name*
  
  First NameLast Name
- Does this require escalation to an executive officer?*
  
  YesNo
- Email of Ban Recipient*
  example@example.com
- Requested Ban End Date*
  
  DayMonthYear
  Date
  Hour Minutes
- Has anything been broken as a result of this incident?
  
  YesNo
- The item that is broken is a*
  
  Till/Access Control System/CCTVPhysical Object
- Please describe what is broken and how it is broken?*
- Attach any Relevant Images
  
  Cancelof
- Should be Empty:

LSU Incident Reporting Tool