Incident Report – Our Lady of Mercy College

Staff, Student or Incident Report Form

Please complete all applicable sections in relation to the incident

Name of School

Address

Name of person completing this form *

1. Details of Injured Person

*Only complete if person was injured. If the incident did not involve a person being injured, please proceed to incident details*

Details *

Details Ext. *

Male
Female
Other

Full Name *

Date of Birth *

Age (in years) *

Year Level (if applicable) *

Address *

2. Incident Details

Date / Time of Incident *

Date

Time

Specific Location: **Please state the location the incident occurred. This could be where in the school/office grounds or an offsite location if the incident occurred outside the school/office grounds *

Type of Activity *

Incident Description - **Please provide a brief description of what occurred in the incident *

Severity *

Parent Notified (Date/Time) - of applicable

Date

Time

Name of Staff Member (on duty, teaching, witnessed incident etc.) *

Witnesses (students, other staff members, member of public) *

First Aider (name if first aid was required) *

Sent to College sick bay? *

Yes
No
Not Applicable

Police, Fire or Ambulance Contacted *

Yes
No

If yes, please provide brief details (which service was contacted, by who, incident #) *

Advised HOLA / Director / Line Manager? *

Yes
No

If yes, please name person advised: (copy) *

Advised Vince Bellini (Principal) - if ambulance, hospital attendance, or GP required *

Yes
No

If yes, please provide method of contact and time *

STAFF INCIDENT ONLY: Workers Compensation (please state if this will be required, please see Michelle Williams, Team Leader - Admin Services for details) *

Yes
No

Any Other Details you would like to add prior to form submission?

Signature *

Clear Signature