Staff, Contractor and Volunteer Incident Form

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 NameLast Name
Submitter's Position*
Submitter's Email*
example@example.com
Incident Date & Time*

DayMonthYear
Hour MinutesAM/PM Option
At which campus did the incident occur?*
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*
What happened? *
Please provide a detailed description of the incident.
Immediate Corrective Action Taken
Was there an injury?*

YesNo
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 packRecommended rest and reassureApplied bandageApplied compression to the woundCleaned 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?

YesNo
Please describe the hazard and how it can be minimised
Comments
Data Use Only
Principal Email
example@example.com
Should be Empty:

Staff, Contractor and Volunteer Incident Form

Data Use Only