AICSE of Incident - Injury Report Form

Incident - Injury Report Form
Please Print Clearly and tick the correct box
Status

EmployeeStudentOther
Work Arrangements

CasualFulltimePart TimeOther
Outcome

Near MissInjury
Details of Injured Person
Name*

PrefixFirst NameLast Name
Gender*

MaleFemaleOther
Student id*
Contact Tel.*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Post CodeCountry
Email Address *
Date and Time of the Injury / Near Miss*

DayMonthYear
DateHourMinutesAM/PM Option
Location*
Describe What happened and how:*
Details of Injury
Nature of Injury (Eg: Burn, Cut, Sprain)*
Cause of Injury (Eg: Fall, Grabbed by person)*
Location on body (Eg: Back, Left Arm)*
Agency (Eg: Lounge Chair, Another Person, Hot Water)*
Assessment*
Treatment Administered
Treatment*
Follow Up / Referral

AmbulanceDoctor / Medical CenterTook over by another First AiderOther
Comments
First Aid provided*

YesNo
First Aiders Name*

PrefixFirst NameMiddle NameLast Name
Position*
Signature*
Date*

DayMonthYear
DateHourMinutesAM/PM Option
If any student undertaking Commercial Cookery gets injured during the practical session in the kitchen, please fill up this form and email to info@aicse.edu.au
Incident - Injury Report Form | V2 - Revised June 2020
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