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
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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Reported By:
Signature:
Details of action taken by Critical Response Team Member:
Were these actions effective in dealing with the Critical Incident?
Yes
No
Are there any preventative measures that can put in place to prevent another similar Critical Incident
Yes
No
If yes, please detail
Have all staff / students affected been offered de-briefing / counselling sessions?
Yes
No
If yes, were these effective?
Yes
No
Recommended follow up action:
Signature
Date
/
Day
/
Month
Year
Date
WH&S recommended action:
Signature
Date
-
Day
-
Month
Year
Date
Media response (if applicable):
Follow Up
Are there any changes / improvements required for our Critical Incident Policy?
Yes
No
If yes, please details
Are there any changes / improvements required for our Critical Incident Policy?
Yes
No
Chief Executive Officer:
Signature:
Date:
/
Day
/
Month
Year
Date
Submit
Should be Empty: