ACCIDENT/INCIDENT REPORT
CENTRE LOCATION:
*
Stokes Valley
Epuni
Wilford
Lower Hutt (Market Grove)
Adventure
Waterloo
Huia
CHILD NAME(S) INVOLVED
*
DATE OF ACCIDENT/INCIDENT
*
-
Day
-
Month
Year
Date
TIME OF ACCIDENT/INCIDENT
*
LOCATION OF ACCIDENT/INCIDENT
*
TYPE
*
accident
incident
illness
environmental
Other
REPORTED BY (STAFF NAME)
*
WITNESSES NAMES (IF ANY)
*
WHAT HAPPENED DURING THE ACCIDENT/INCIDENT? PLEASE EXPLAIN IN AS MUCH DETAIL AS POSSIBLE
*
DESCRIBE ANY INJURY OR ILLNESS (WHAT PART OF THE BODY IS AFFECTED AND HOW?
*
TREATMENT IF ANY
*
STAFF NAME
*
First Name
Last Name
Submit
Should be Empty: