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Complete the following incident report 

Table 3 Incident report

Details of person completing this record

Name: Fariha Nahar

Position/Role: Educator/ School learning support officer.

Date:  Monday 15th February 2022

Time: 4:00 PM

 

Location: Australia

Signature: Fariha Nahar

Details of witness to incident

Name: Mary Smith

Home address:  16 That Street, This town, 1234

Phone: 0478893483

Business owner/manager/Authorised supervisor

Name:  Vivian

Business name: 

Business address 

Details of the person with illness or injury

Name:  ] Jane Smith

Date of birth:   1/01/2018

Home address:  16 That Street, This town, 1234

☒ Child or young person 

Non-employee- ☐ Visitor 

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):  

Description of occurrence (what happened and how): 

Nature of injury or illness (Indicate the part of the body affected. You may want to draw a diagram): 

Action taken

Details of action taken (including first aid, administration of medication, etc.).

 

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  ☐No

If yes to either of the above, provide details: 

Have any steps been taken to prevent or minimise this type of incident in the future? 

If yes, provide details: 

Notifications (including attempted notifications)

When and how the workplace supervisor was notified of the incident/injury: 

 

 

If the incident was involving a child or young person, please provide details of when and how you contacted their parents/guardian/carer:  

Date/Time: 

If applicable, parental acknowledgement:

I, _______________________________________(name of parent/guardian/carer) have been notified of my child’s ☐incident ☐injury ☐trauma ☐illness. 

Signature: 

If applicable, when and how other agencies/regulatory authorities were notified:

Date/time: 

SCIENCE
HEALTH SCIENCE
NURSING
CHILDCARE HLTWHS003

 
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