Incident Injury Report Gordonvale

Gordonvale Incident Injury Report

Date of Report

Staff Member Name

Child Details

Child's Name

Child's Date of Birth

Child's Age

Learning Room

Incident / Injury

Time of Incident/Injury

Date of Incident/Injury

Location

Circumstances leading to Incident/Injury (if necessary, record child's temperature)

Product or Structures Involved

Nature of Injury

Tick relevant type of injury

Name of Witness

Action Taken

Please note details of action taken including first aid administration of medication and child temperature recording. NB: Record LOCATION and TIME each action is taken

Injury Position on body

Medical Person contacted?

If yes, provide details

Parent Guardian Notification

Parent or Guardian Notified?

Date of Notification or Attempted Notification

How was the Parent or Guardian Notified?

Parent or Guardian Name

Time notified (including attempts)

Additional Comments

Parent Guardian Acknowledgement

I, Name of Parent/Guardian have been notified of my child's illness.

1.Do you require any follow up information on this incident
2.Would you like to request a meeting with our staff?
Parent / Guardian Signature

Date of Parent / Guardian Signature

Nominated Supervisor / Educator Name

Supervisor Signature

Date of Supervisor Signature

Staff Use Only

Preventative action/follow up taken by Educator (to be completed by Reporting Staff Member)

Incident reported to:

Follow up conversations with staff:

If yes, give details

Follow up conversation with parents/guardians

If yes, is record of conversation noted on child's file?

Date recorded in the JK Record of Incident/Injury Tracking Tool and/or Illness Report?

Report Filed

Staff Signature

Date

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