Accident / Incident Reporting Form

  • Accident / Incident Reporting Form

  • Accident Reporting Form

    Please Note: All reportable incidents must be reported. All reported incidents are: used for trend analysis, future planning and reporting to the appropriate authorities as required. kept on file in the CYC Waihola office. It is preferable that this form is completed within 24 hours of the incident occurring. All incidents on the Incident Severity Table that are level 3 and above will be reported on the National Incident Database (NID) and incidents level 6 and above are reported to Worksafe as well. The contents of form will be kept confidential to CYC Waihola management. Only summarized details will be given discerningly by the Operations Manager to caregivers and outside agencies if requested
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  • Key Person

    The key person is generally the main victim in the accident. You can list others (or other key people) later.

  • Incident Details

  • Other People Involved:

    Please provide names of all other people involved.

    • List anyone else that could have been harmed
    • List what the supervision present was and note any qualifications if applicable
    • Note the numbers of participants in the activity

  • Accident Summary:

    Provide detail following:

    • what led to incident
    • what actually happened
    • key things that were said or done prior or during the incident
    • note any damage to property
    • note any other important facts

  • Environmental Conditions

  • After The Accident

    Action Taken

    Please provide details of what happened after the incident

    • Who took the action
    • What were the supervision levels during any action taken
    • Note key things that were said
    • Note any other important facts
  • Should be Empty: