Staff, Contractor and Volunteer Incident Form
Use this form to report safety incidents involving staff, contractors, and volunteers on Amity College premises or during excursions.
Title
This value is automatically populated.
Submitter's Name
*
First Name
Last Name
Submitter's Position
*
Please Select
Staff Member
Volunteer
Visitor
Contractor
Submitter's Email
*
example@example.com
Incident Date & Time
*
/
Day
/
Month
Year
Date Picker Icon
Hour Minutes
AM
PM
AM/PM Option
At which campus did the incident occur?
*
Please Select
Prestons BHS
Prestons GHS
Prestons Primary
Auburn
Illawarra
Leppington
Specific Location of the incident
Give the specific location of the incident.
Name of the person/s involved
*
Write the name of the person/s involved in the incident.
Position of the person involved
*
Please Select
Staff Member
Volunteer
Visitor
Contractor
What happened?
*
Please provide a detailed description of the incident.
Immediate Corrective Action Taken
Was there an injury?
*
Yes
No
If an injury has occurred, please indicate the location by marking the injured part of the body in the picture below
Injury Details
You may provide details of the injury.
Nature of first aid provided (if applicable)
Provided ice pack
Recommended rest and reassure
Applied bandage
Applied compression to the wound
Cleaned the affected area
Details of the first aid provided
If you would like to add more details of the first aid, you can add them here.
Who provided the first aid?
Witness 1
Write the name of witness if there was any
Witness 2
Write the name of witness if there was any
Do you want to submit a hazard in relation with this incident?
Yes
No
Please describe the hazard and how it can be minimised
Comments
Data Use Only
Principal Email
example@example.com
Submit
Should be Empty: