International Student Handbook - The Southport School

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40 The Southport School International Handbook Incident Report / Record Part A Type of Incident ◦ injury ◦ serious bodily injury ◦ work caused illness ◦ dangerous event Notify DTIR, WH&S ◦ Yes ◦ No Was injury/illness fatal? ◦ Yes ◦ No Details of Injured Person Given names .................................................................... Surname.................................................................................. Date of Birth ................................ ◦ Male ◦ Female Residential Address ............................................................................................................................................................... Telephone: Work ....................................... Home ..................................... Mobile ............................................................. Employee of TSS? ◦ Yes ◦ No Student of TSS? ◦ Yes ◦No Occupation ............................................................. Student Number ............................................ ◦ Full time ◦ Casual ◦ Part Time ◦ Volunteer Boarder ◦ Yes ◦ No Non Employee ◦ Member of the Public ◦ Contractor Contractor’s / Employer’s Name and Address .............................................................................................................. ................................................................................................................................................................................................. Nature of Injury or Work Caused Illness, e.g. fracture, sprain and strain, burns, etc. .................................................. ................................................................................................................................................................................................. Bodily Location of Injury or Work Caused Illness .............................................................................................................. ◦ Medical Treatment ◦ nil ◦ self ◦ first aid attendant ◦ doctor only ◦ hospital Treatment: .............................................................................................................................................................................. Name of Person Providing Treatment: ............................................. Contact No ............................................................. Admitted to hospital? ◦ Yes ◦ No Hospital Name................................................................................................. Mechanism of injury / disease ◦ Falls, trips and slips ◦ Biological factors ◦ Body stressing ◦ Heat radiation and electricity ◦ Sound and Pressure ◦ Hitting Objects with Part of Body ◦ Mental Stress ◦ Chemicals and Other Substances ◦ Other and unspecified mechanisms of injury
The Southport School International Handbook 41 Agency or injury / disease ◦ Machinery and (mainly) fixed plants ◦ Environmental agencies ◦ Powered equipment, tools and appliances ◦ Chemicals and chemical products ◦ Mobile Plant and Transport ◦ Materials and Substances ◦ Other and Unspecified Agencies ◦ Non-Powered Hand Tools, Appliances and Equipment ◦ Animal, human and biological agencies Detail of Incident Date ..................................................................... Time ..................................... Where did the event happen? ............................................................................................................................................... Describe how the incident happened (what started the sequence of events, the sequence of events, the final thing that happened. (Attach page if necessary). ................................................................................................................................................................................................. ................................................................................................................................................................................................. ................................................................................................................................................................................................. What factors do you believe contributed to the Incident? 1. ............................................................................................................................................................................................. 2. ............................................................................................................................................................................................. 3. ............................................................................................................................................................................................. 4. ............................................................................................................................................................................................. 5. ............................................................................................................................................................................................. Property Damage: ◦ Yes ◦ No Owner .................................................................................................................... Was a motor vehicle involved? ◦ Yes ◦ No Owner ................................................................................................. Details/Description of Damage ............................................................................................................................................ ................................................................................................................................................................................................. ................................................................................................................................................................................................. Outcome of Injured Person ◦ Returned to class/work ................... am/pm on ........ / ......... / ........ (date). ◦ Has not returned to class/work Signature of person completing Part A: Signature ..................................................... Name ..................................................... Date................................................. Parent / Guardian notified? ◦ Yes ◦ No Next of kin/contractor’s employer notified? ◦ Yes ◦ No Details .............................................................................
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International Student Handbook - The Southport School

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