Critical Incident Report Form
(Use additional sheets where required and attach)
Type of critical incident (please tick)
*
Missing student
Severe verbal or psychological aggression
Natural disaster
Death
Serious injury
Sexual assault
Domestic violence
Drug or alcohol abuse
Mental health issue
Other
Details of Critical Incident
Date:
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location:
Person(s) Involved (Including Witnesses)
Rows
Name
Contact Number
Email
1.
2.
3.
4.
Description of Critical Incident
Description of Injury (if applicable)
Description of Damage (if applicable)
Reported to Police?
Yes
No
Did any other emergency service attend?
Yes
No
If yes, attach copy of report
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Signature:
*
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Reported By:
Submit
Should be Empty: