Critical Incident Report Form

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Section 1 – Details of Injured Person

Full Name

Student No

Contact Tel

Mobile

Address Email

Section 2 – Details of Incident

Date of Incident

Time

Location of Incident

Reported To

Position Title

Description of Incident

Section 3 – Details of Injury and Treatment

Description of Injury Treatment Provided

None Required

First Aid

Treated By

Taken to Doctors Surgery

Taken to Hospital

Ambulance Called and Attended

Treatment Details Further Treatment Recommended

Section 4 – Witnesses to Incident

Witness Name 1

Contact

Witness 1 Address

Witness Name 2

Contact

Witness 2 Address

Section 5 – Signatures

Supervisor Name

Supervisor Position

First Aider Name

First Aider Position

Director Name

Director Position

Digital Signature

Admin Use Only

Reported to Insure

Reported to Worksafe

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Critical Incident Report Form

Section 1 – Details of Injured Person

Section 2 – Details of Incident

Section 3 – Details of Injury and Treatment

Section 4 – Witnesses to Incident

Section 5 – Signatures

Digital Signature

Admin Use Only

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