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PAK Student Incident Report Form

If your incident relates specifically to child safety or wellbeing including aggression or bullying DO NOT use this form unless the student has sustained a physical injury due to any of the above.

CONTACT the Wellbeing Team or your Head of House to report this type incident.

Your Name *

Your Email *

Type of Incident: *

Safety Incident - accident or incident resulting in injury, medical care or treatment required
Hazard or near miss - with or without property damage

Incident Date: *

Incident Time:

Details of Incident: *

Location the incident *

On Campus - Playground
On Campus - Classroom
On Campus - Sports activity
Off Campus - Sports activity
Off Campus - Excursion
Off Campus - Beacon Explorers activity
Other

Please specify the exact location of incident (room, building or grounds location if ON CAMPUS/address if OFF CAMPUS)) *

Students First and Last Name *

Students Synergetic ID (if known at time of submission)

Students Year Level/Tutor/Class *

Was there property damage? *

Yes

If you selected Other, please specify here: *

Indicate which part of the body was injured *

Click image to mark relevant area(s)

Was an ambulance called? *

Yes

Nature of first aid provided *

Who provided first aid? *

Was the student taken to the Health Centre (if on campus) *

Yes

Were any other students injured? (If yes, please complete a separate incident report) *

Yes

Name/s of witnesses (if any) *

Parents have been notified? *

Yes

Preventative action proposed or taken to stop the incident reoccuring *

Review of Curriculum
Review/Reinforce/Reiterate Procedures
Review Systems
Review the Environment
Review Personal Protective Clothing/Item
Review Training Provisions
Referred to the School’s Safety/OHS or Risk Management Committee or Representative
No Preventative Action Taken/Intended

Describe the preventative actions taken in further detail: *

Please upload any other documents/images in relation to the management, treatment or review of this incident

List of Allowed file types

Approvals

A number of approval stages need to be completed before this submission can be accepted.

PAK Health Centre

Appropriate approvers from the PAK Health Centre group will be automatically allocated for this approval stage.

PAK OHS

Appropriate approvers from the PAK OHS group will be automatically allocated for this approval stage.