Incident Report

Use this form for types of incidents involving staff, students, visitors, and contractors. Incidents should be reported within 24 Hours.

Details of person completing the report

Reported by: *

Email Address *

Contact No.

Details of person involved/impacted by the incident

Full Name

Date of Birth

Contact No.

Email Address

TKC Community Type *

Has student's parent/guardian been informed?

Name of Guardian (if under 18 years)

Incident Description

Incident Type

Date of Incident *

Time of incident *

Location of incident *

Incident Description (what happened) *

What caused the incident? *

Seriousness of Risk

Names of any witnesses and contact details

Details of injury/illness

Did an injury occur?

Location of injury (on body)

Treatment required

Address / location of treatment

Details of property damage or loss

Did property damage or loss occur *

Nature of property damage or loss

Lost or stolen physical/tangible propertyLost or stolen intangible property (e.g. confidential information, data)Damage to motor vehicleDamage to clothing/equipment/machineryStructural damage to buildingFines/penalties

Description of property (e.g. Vehicle- make/model/year)

Location of loss/damage

Details of action taken after the incident to resolve the incident and to manage any ongoing risks

Action taken and by whom

Signature *

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Date:

Please upload any photographs, reports, etc

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Incident - Assess | Respond | Notify

This section of the form must be completed by the Principal or the College Health and Safety Representative to assess and respond to the incident in alignment with the College's WHS policies and procedures. This data will appear on the Incident Register,

Likelihood of further risk

Impact

Does the incident require further investigation? *

YesNo

If no, reason

Were College policies and procedures followed? *

YesNo

If no, reason

Comment/instructions for personnel

Review to be conducted by: *

Work Health Safety CommitteePrincipal

Who completed this assessment *

Position *

Incident Notifications

Certain incidents listed below, require further notification to external parties:

Reportable Incidents	Notifiable Incidents	Section 42 of the Teacher Registration Act 2012	Reportable Conduct Scheme
Governing Body and Director General of DoE	Worksafe 1800 678 198	Teachers Registration Board of Western Australia	Ombudsman Western Australia 08 9220 7472
More Information	More Information	More Information	More Information
Contact immediately by phone and submit form within 48 Hours of incident	Contact by phone immediately and submit the form within 24 Hours of incident. Ensure to preserve the site	Notifications must be given within 7 days after the day on which the later of the two circumstances occurs	Report online using theOnline Form

Is this a Reportable Incident

YesNo

Is this a Notifiable Incident

YesNo

Does this fall under Section 42 of the Teacher Registration Act 2012 (Act)

YesNo

Reportable Conduct Scheme incident type

YesNo

Reportable Incident Type

Notifiable Incident Type

Section 42 Type

Reportable Conduct Scheme Type

All Critical Incidents will need to be added to the Critical Incident Register

Incident - Review | Communicate

Enter details of outcomes and/or review at the next Safety and Health Committee Meeting. This data will appear on the Incident Register.

Please note any recommended changes to polices and/or procedures

Changes to be communicated to: (Can choose multiple)

StaffStudentsVolunteersParents

How will community be informed? (Can choose multiple)

Email Staff MeetingSEQTA NoticeboardReception Noticeboard

Upload Incident Investigation Report (if applicable)

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Upload other documents (photographs, reports, etc)

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Reviewed by

Position

Signature

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Date

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