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PHONE

+61 3 6211 4911

EMAIL

collegiate@collegiate.tas.edu.au

ADDRESS

218 Macquarie Street, Hobart, Tasmania 7000

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Injury/Incident Form

Injury/Incident Form

Injury/incident form

When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Full name of person impacted(Required)

First Last

Date of birth of person impacted

Note: this is only required where the person impacted/involved is an ELC child/student.

Month

Day

Year

Home campus(Required)

Please select the Home Campus of the Student or Staff Member. If the person involved does not have a Home Campus (for example a visitor), then please select ‘Other” and specify.

Junior – ELC

Junior School K – 4

Middle School

Senior School

Other

Location incident occured(Required)

DMCRC Rowing Club

Boarding House

Ham Common

Collegiate Pool

OSHC (Outside school hours care)

Other

Was the person a:(Required)

Staff member

Student

Volunteer

Contractor

Visitor

Other

Date Occured(Required)

Month

Day

Year

Timeframe(Required)

Before School

In class

Between classes

Recess

Lunch

After School (school day)

Weekend

Holiday

Public Holiday

Incident/injury that occured(Required)

Please give us the details of the injury or incident

Incident type(Required)

Injury

Illness

Near miss

Scale of Injury

Minor (Injury checked, and minor first aid applied and sent back to class (e.g. bandaid or ice pack))

Moderate (Minor injury requiring monitoring

Serious (Injury or illness requiring follow up treatment by doctor)

Severe (Injury or illness requiring follow up treatment by doctor)

Critical (Injury or illness requiring follow up treatment by doctor)

Was the injury sports related?

Yes

No

Was First Aid provided?

Yes

No

Was any other person impacted?

If yes, please name the person(s) impacted/involved. Complete another form for each person significantly impacted/involved.

Yes

No

Name of other person impacted

First Last

Was there property damage?

Yes

No

Unsure

Were there any witnesses?

If yes, please provide the witness/es names and their contact details

Yes

No

Names and contact details of witnesses

Immediate Corrective Action Taken

Please describe any immediate action taken to prevent a recurrence eg. barrier erected, equipment removed from use, staff notified etc.

CAPTCHA

Email

This field is for validation purposes and should be left unchanged.

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Phone:
+61 3 6211 4911
Email:
collegiate@collegiate.tas.edu.au
Address:
218 Macquarie Street, Hobart, Tasmania 7000

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Acknowledgement of Country

St Michael’s Collegiate School is committed to recognising the significance of Aboriginal and Torres Strait Islander cultures, histories and traditions. Our future is committed to reinforcing the values of inclusion, respect and diversity in all our actions through the process of reconciliation and empowerment. We acknowledge the muwinina people as the first inhabitants of nipaluna, the land on which our school stands

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