Incident Report Form

This report is to be completed following an incident at Lead College Pty Ltd

Critical incidents are events that occur on or in the vicinity of the campus that are disturbing, sudden or unexpected. Critical incidents include, but are not limited to theft, medical emergencies, violence, accidents, fire, injury or death of a student, staff member or member of the public, threats of harm, physical assault, sexual or racial abuse, bomb threat.

Non-Critical Incident: An incident with minimal or no injury, limited impact, and no immediate threat to safety or operations.

Incident Classification*

Type of Incident*

Name*

PrefixFirst NameLast Name

Gender*

MaleFemaleOther

Student ID*

Contact Telephone*

Address*

Street Address

Street Address Line 2

CityState / Province

Post CodeCountry

Email Address *

Staff Name*

First NameLast Name

Staff Email*

example@example.com

Staff Phone

Area CodePhone Number

Date and Time *

DateHourMinutesAM/PM Option

Campus*

Location

Where in the campus?

Describe what happened and how:*

Other Parties Involved*

YesNo

Please enter the details

Other persons / Organisations involved*

YesNo

Please enter details*

Name of Injured*

Phone*

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*

Additional details

Were there any damage to property*

YesNo

Were there any injuries*

YesNo

Are you direct witness*

YesNo

Did you report to campus manager?*

YesNo

Where were you at the time of incident *

Treatment*

Follow Up / Referral

Action taken*

Comments

First Aid provided*

YesNo

First Aiders Name*

PrefixFirst NameMiddle NameLast Name

Are you able to upload CC TV footage*

YesNo

Upload photo(s) of the injury taken at the time of incident / relevant photos of the incident*

Browse Files

Signature*

Date*

DateHourMinutesAM/PM Option

Please review the critical incident policy on our website www.leadcollege.edu.au

Incident - Injury Report Form | V2 - Revised June 2023

ABN: 63 604 422 853

Incident Report Form

Reporter Details

Incident Report Form

Incident Details

Details of Injured

Immediate Actions taken

Evidences