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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