Incident Report – Our Lady of Mercy College

Name of School

Address

Contact Person

Policy Number

Client Number

Phone

Details *

Details Ext. *

Name *

Date of Birth *

Age (in years) *

Year Level (if applicable) *

Address *

Date / Time of Incident

Date

Time

Type of Activity *

Accident Description *

Details *

Accident Site *

Parent Notified (Date/Time)

Date

Time

Name of Teacher(s) on Duty

Witnesses

First Aider

Type of Injury *

Location of Injury *

Severity *

Has a Claim been made? *

Details of Claim