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Asked by GrandNeutronStarling20
Complete the following incident reportÂ
Table 3 Incident report
Details of person completing this record
Name: Fariha Nahar
Position/Role: Educator/ School learning support officer.
Date: Â Monday 15th February 2022
Time: 4:00 PM
Â
Location: Australia
Signature: Fariha Nahar
Details of witness to incident
Name: Mary Smith
Home address:Â Â 16 That Street, This town, 1234
Phone:Â 0478893483
Business owner/manager/Authorised supervisor
Name:Â Vivian
Business name:Â
Business addressÂ
Details of the person with illness or injury
Name:Â ] Jane Smith
Date of birth:Â Â 1/01/2018
Home address:Â 16 That Street, This town, 1234
☒ Child or young personÂ
Non-employee- ☠VisitorÂ
Employee-☠Full time ☠Part-time☠Casual ☠Contractor
Details of occurrence
Date of incident or illness first noticed: 1/01/2018
Time of occurrence: 4.00 pm
Where did the incident occur (please be exact): Â
Description of occurrence (what happened and how):Â
Nature of injury or illness (Indicate the part of the body affected. You may want to draw a diagram):Â
Action taken
Details of action taken (including first aid, administration of medication, etc.).
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Did emergency services attend? ☠Yes ☠No
If yes, time emergency services contacted:
If yes, time emergency services arrived:
Was medical attention sought from a registered practitioner / hospital? ☠Yes â˜No
If yes to either of the above, provide details:Â
Have any steps been taken to prevent or minimise this type of incident in the future?Â
If yes, provide details:Â
Notifications (including attempted notifications)
When and how the workplace supervisor was notified of the incident/injury:Â
Â
Â
If the incident was involving a child or young person, please provide details of when and how you contacted their parents/guardian/carer: Â
Date/Time:Â
If applicable, parental acknowledgement:
I, _______________________________________(name of parent/guardian/carer) have been notified of my child’s â˜incident â˜injury â˜trauma â˜illness.Â
Signature:Â
If applicable, when and how other agencies/regulatory authorities were notified:
Date/time:Â
SCIENCE
HEALTH SCIENCE
NURSING
CHILDCARE HLTWHS003
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