Download Incident, injury, trauma and illness record

Incident, injury, trauma and illness record
Detailsofpersoncompletingthisrecord
Name:..................................................................................Position/role:.......................................................................
Dateandtimerecordwasmade......../......./..............................Signature:.....................................................................
Childdetails
Child’sfullname:...............................................................................................................................................................
Dateofbirth:......../......../........Age:..................Gender:oMaleoFemale
Incidentdetails
Incidentdate:......../......../........Time:.................am/pmLocation:..............................................................................
Nameofwitness:................................................................................................................................................................
Witnesssignature:.....................................................................................................................Date:......../......../...........
Generalactivityatthetimeofincident/injury/trauma/illness:........................................................................................
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Causeofinjury/trauma:......................................................................................................................................................
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Circumstancessurroundinganyillness,includingapparentsymptoms:............................................................................
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Circumstancesifchildappearedtobemissingorotherwiseunaccountedfor(inclduration,whofoundchildetc):................
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Circumstancesifchildappearedtohavebeentakenorremovedfromserviceorwaslockedin/outofservice(inclwho
tookthechild,duration):..........................................................................................................................................................
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Natureofinjury/trauma/illness:
Indicateondiagramthepartofbodyaffected
o Abrasion/Scrape
o Eyeinjury
o Allergicreaction(not
anaphylaxis
o Infectiousdisease
(inclgastrointestinal)
o Amputation
o Hightemperature
o Anaphylaxis
o Ingestion/inhalation/
insertion
o Asthma/respiratory
o Bitewound
o Bruise
o Brokenbone/fracture/
dislocation
o Burn/sunburn
o Choking
o Concussion
o Crush/jam
o Cut/openwound
o Drowning(non-fatal)
o Electricshock
o Internalinjury/Infection
o Poisoning
o Rash
o Respiratory
o Seizure/unconscious/
convulsion
o Sprain/swelling
o Stabbing/piercing
o Tooth
o Venomousbite/sting
o Other(pleasespecify)
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ActionTaken
Detailsofactiontaken(includingfirstaid,administrationofmedicationetc):...............................................................................
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Didemergencyservicesattend?:Yes/No
Wasmedicalattentionsoughtfromaregisteredpractitioner/hospital?:Yes/No
Ifyestoeitheroftheabove,providedetails:...................................................................................................................
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Haveanystepsbeentakentopreventorminimisethistypeofincidentinthefuture?:…...............................................
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Notifications(includingattemptednotifications)
Parent/guardian:................................................................................Time:...........am/pmDate:......../......../........
Director/educator/coordinator:.........................................................Time:............am/pmDate:......../......../........
Otheragency(ifapplicable):..............................................................Time:............am/pmDate:......../......../........
Regulatoryauthority(ifapplicable):.................................................Time:.............am/pmDate:......../......../........
Parentalacknowledgement:
I..........................................................................................................................................................................................
(nameofparent/guardian)
havebeennotifiedofmychild’sincident/injury/trauma/illness.
(Pleasecircle)
Signature:......................................................................................................................... Date:......../......../........
Additionalnotes:
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