Critical Incident Debrief Flow-Chart - Surf Life Saving NSW

ACKNOWLEDGEMENTS
This document is intended for use by Surf Life Saving Duty Officers, Emergency Coordinators and other
delegated Officers.
This document was produced by Surf Life Saving New South Wales. SLSNSW would like to acknowledge the
partnership of NSW Police, the Australian Lifeguard Service and AccessEAP in supporting this program.
Surf Life Saving New South Wales
3 Narabang Way, Belrose NSW
PO Box 307, Belrose NSW 2085 Australia
PH +61 (02) 9471 8000
Fax +61 (02) 9471 8001
E experts@surflifesaving.com.au
W www.surflifesaving.com.au
ABN 93 827 748 379
© Surf Life Saving New South Wales 2010

Contents
Critical Incident Debrief Overview..................................................................................page 4
Section 1: Operational Debrief.......................................................................................page 5
Section 2: Emotive Debrief............................................................................................page 5-7
Appendices
Appendix 1-Critical Incident Debrief Log:..................................................................page 8-13
Appendix 2-Critical Incident Audit Form:.................................................................page 14-20
Appendix 3-Notification of Injury Form:...................................................................page 21-23
Appendix 4-WorkCover Form:...................................................................................page 24-29
Appendix 5-Witness Statement Form: .................................................................... page 30-33

Overview
Purpose
It is the aim of this document to bring together or reference all relevant procedures/processes and
provide consistent and structured delivery of effective Critical Incident Debriefing.
What is a „Critical Incident‟?
The environment in which surf life saving operates has the potential for members to be involved in
serious incidents of a high-intensity and traumatic nature, and which do often involve death, serious
injury and/or significant risk to lifesaving personnel. These are referred to as ‘critical incidents’.
Generally critical incidents are defined by surf life saving as either (or a combination of the following:
Incident resulting in death (incl successful CPR, body recovery)
Incident resulting in serious/major injury
Incident whereby a member of SLS is seriously injured
Incident whereby a member of the public is injured by lifesaving personnel/equipment
In such cases a Critical Incident Debrief (as outlined in this document) should be undertaken within
the RECOVERY PHASE of the incident.
Why should a Critical Incident Debrief be undertaken?
A critical incident debrief is undertaken to ensure that:
1) Member welfare/support is optimised
2) The ability to re-establish core lifesaving services is achieved
3) Obligatory paperwork and data is recorded, collected and forwarded appropriately
4) The Surf Life Saving response is documented for future review or for legal reasons (if required)
5) Surf Life Saving is best positioned (through effective data collection) to provide drowning
prevention recommendations to the Coroner and relevant local government authorities.
Who should deliver/lead Critical Incident Debrief?
The Branch Duty Officer (or equivalent) should lead every Critical Incident Debrief as part of the
incident Recovery Phase. If a Duty Officer is not available an appropriate Branch or Club Officer
should be tasked to deliver the debrief by the Branch Duty Officer.
When/where should a Critical Incident Debrief be undertaken?
As soon as possible after the incident has finished, at a location which does not require much travel
(i.e the SLSC). The debrief should be conducted in a secure room, with no thoroughfare and isolated
from any media or public interference.
Who should attend?
All SLS personnel who were involved in the incident should attend, regardless of the level of
involvement. Delivery of the debrief ASAP is important in this respect to ensure full attendance. Any
personnel not in attendance should be recorded in the debrief form for further contact if necessary.
External agency / public involvement
A joint SLS-External agency debrief can be organised following or at a later date, involving the key
senior members involved (Duty Officer, Patrol Captain, Senior Lifeguard, Police Sgt etc).

What is involved in a Critical Incident Debrief?
The critical incident process can be broken into two separate parts:
1) Operational Debrief
2) Emotive Debrief (Psychological First Aid)
3) Expert Counseling (as required post incident )
1. Operational Debrief
The Duty Officer shall lead/coordinate the Operational Debrief and record member involvement (who
was involved and in what capacity), contact details and the sequence of events - from first notification
through to the end of the incident. Key actions and timings are recorded as best able within the
sequence of events.
Contributing factors to the incident, positive/successful parts of the response and/or issue/concerns
are discussed and documented.
The relevant and appropriate forms/logs should be completed in full and forwarded to the necessary
officers by the Duty Officer; these are:
Log/Form Completed By When Completed (reason) Notes
Debrief Form Duty Officer All Critical Incident Debriefs Sent to Branch DOL
Patrol Log Patrol Captain All patrols Copy sent to Branch DOL
Incident Log
Patrol Captain or All critical incidents
Copy sent to Branch DOL
Duty Officer
Witness Statement Form Member For any criminal incident
Sent to Branch DOL
For any incident where SLS
personnel have been seriously
injured
Where a member of the public has
been injured by surf lifesaving
personnel/equipment
A witness statement form
should be completed by
members individually
under the
supervision/support of the
Duty Officer.
As per form instructions
Workcover Form Member Where a member has received an
injury
Critical Incident Audit Form Duty Officer All critical incidents Sent to Branch DOL
Additional forms can be downloaded and printed from www.surflifesaving.com.au
2. Emotive Debrief (Psychological First Aid)
Critical incidents can have a strong emotional impact, which can overwhelm the usually effective
coping skills of the individual or group. Members may experience a number of different reactions to a
critical incident, all of which are completely normal. Psychological First Aid (Peer Support) focuses on
member wellbeing and coping, and will form a significant part of the duty officer role when dealing
with critical incidents.
The Duty Officer shall lead the Emotive Debrief session, and in essence the first part of can
commence (covertly) within the operational debrief, specifically in the emotive debrief the Duty Officer
will:
Observe and record any members displaying obvious emotional trauma
Outline the effects that traumatic events can have on people (straight away and delayed on-set)
Outline what support is available and how to access it (hotline, counselling sessions)
Provide supporting information (brochures, contact information)
Outline the process ‘from here’ as far as follow-up, accessing additional support etc
Note: Additional trained ‘Peer Support’ Officers may be used to deliver this session if required (i.e if
the Duty Officer is not available or has not been trained/resourced)

Supporting Resources and Counselling Options
Resource Details Availability
Brochure – Information
for Duty Officers
Brochure – Critical
Incident Peer Support
Service
Information for Duty Officers and Peer
Support Officers
Information for members and their
families/friends
From Duty Officer or Peer Support
Officer
From Duty Officer or Peer Support
Officer
AccessEAP Hotline 1800 818 728 Free call 24/7
AccessEAP Counselling
Session
AccessEAP Website
1-on-1 counselling session
Ph: 1800 818 728
For more information of trauma and
support options
www.accesseap.com.au
Free service
Organised by the member of their
family
Free web based information
3. Expert Counseling (AccessEAP)
SLSNSW has a contract with a private counselling organisation called AccessEAP.
AccessEAP plays the following roles in SLS Critical Incidents:
Provision of trauma information/brochures
Provision of free 24/7 counselling hotline to members
Provision of psychological first aid (emotive debrief) training to Branch Duty Officers and Peer
Support Officers
Provision of group counselling sessions for significantly traumatic critical incidents
Provision of ‘follow-up’ individual counselling session for members
Accessing AccessEAP Counsellors
Same-day counselling session
If a significantly traumatic incident occurs, a AccessEAP Counsellor can be requested to attend the
Critical Incident Debrief to deliver a group counselling session (replacing the emotive debrief session).
This can be requested by the Duty Officer (or delegated Officer) by contacting AccessEAP on 1800
818 728
Note: Availability will depend on location and availability of a counsellor.
Individual Counselling Session (post-incident)
Members (or their parents) can request an individual counselling session as they deem necessary by
contacting AccessEAP on 1800 818 728
4. Follow Up Welfare Check
As the symptoms of trauma on members can present themselves some time after the incident, It is
important that the Branch Duty Officer involved, Branch Director of Lifesaving, Club Captain and Club
President communicate post-incident to discuss the event and the need to ensure that the members
involved are monitored and provided ongoing support (if required).

Critical Incident Debrief Flow-Chart
During Patrol Hours
After-Hours Response
Patrol deals with incident as per training
and resources available
Duty Officer Coordinate’s response
Attends scene if able or responds other
Duty Officer or delegated Officer
SurfCom coordinates ambulance/
helicopter/police/other support
Callout teams/services responded as
required
Branch Duty Officer (or delegated officer)
responds to the incident and provides
support as required through RESPONSE
and RECOVERY PHASE
Advises (as able):
Branch Duty Officer
Branch Director of
Lifesaving
13SURF
Club Captain
Branch Duty Officer (or delegated officer)
responds to the incident and provides
support as required through RESPONSE
and RECOVERY PHASE
1. Runs operational group
debrief for all involved
2. Delivers the emotive group
debrief for all involved
Record who, when, where, how, why
details. Using Critical Incident
Debrief template
Provides brochures and support
information
Duty Officer follows steps 1-6
for Critical Incident Debrief
3. Ensures all paperwork
is completed
4. Completes Critical Incident
Audit
With photos if able
5. All paperwork forwarded to
Branch DOL
Within 48hours
Service Response
Duty Officer Response
6. Branch DOL contacted & briefed
State DOL, Lifesaving Manager,
Club Captain, Club President briefed
ASAP

CRITICAL INCIDENT DEBRIEF LOG
Name of Facilitator (Duty Officer):
Time:
Date:
Location:
Introduction
Preparation
Are you dressed neat and tidy and in an appropriate shirt or polo?
Debrief should take place in a quiet room/area – secure from thoroughfare/media/public?
Do you have the required forms/logs/paperwork?
Are all members involved in attendance?
Any junior members involved – have their parents been invited (if able)
Welcoming Address
Your address to the assembled people involved will include:-
Your name and position within the organisation
A brief and relevant personal surf background
That the debrief will take around 1hour and be split into 2 parts (operational and emotive debrief)
The purpose of the debrief is:
- Ensure all paperwork and information completed
- Record key actions/times/sequence of events for internal records, police records, possible coronial inquests and
media (to ensure professional and correct information is available from SLS)
- Record all members involved and provide traumatic counselling information and support if required
What will happen with information given at debrief?
- Recorded internally as per SLS logs and SurfGuard. Provided externally to NSW Police or Coroner (if requested)
specific member information will not be disclosed to any other person or organisation outside of SLSNSW and the
Club, without their prior agreement (i.e Media).
Ask permission to record the debrief (if able) - the tapes disclosure will be treated in the same way as any notes taken
from the debrief
Reinforce that the purpose of the debrief is not to apportion blame, but record the facts.
Record of Attendance
# Name Phone Email Witness Statement
Required? Y/N
1
2
3
4
5
6
7
8
9
9
10
11
12
13

Establish the facts
Date of Incident
Time of Incident (Start)
Type of Activity
Number of Patients
Did anyone witness patient prior?
Exact Location
Tide
Weather
Wind Strength
Wind Direction
Swell - Wave Size
Head Count (at time of incident)
Number on Patrol (bronze)
Number of Lifesavers Assisting
Number of Public Assisting
Nature of Public Assisting
Nature of Others Assisting
Determine the sequence and nature of events
Get the group talking about the incident from when and how the incident was first identified/communicated?
Explore the situation and encourage everybody to talk through their involvement.
This may take some time as you establish who, when, how many/much, for how long, assistance by others, and handover to
others…
Add further lines if necessary - more information is better than less information. Use an additional pad if necessary.
Be conscious of outspoken individuals ‘leading’ the conversation – ask specific members their recollections and thoughts as
required.
Time
(approx)
What Happened?
First notification:

Involvement Summary
Who did what? (e.g IRB Driver, , First Aid Provider, Defibrillator, Crowd Control etc)
Write down and summarise all known people and their involvement in the incident (they may have more than one role)
1
Name
Role / Involvement
2
3
4
5
6
7
8
9
10
11
12
13
Incident Summary
Agree amongst all involved on a brief written statement can be written of what happened without worrying about why it
happened
If you were to summarise in a couple of sentences how would you do so?

Measure of Change
Open a discussion on how the incident went from a lifesaving perspective (good and requiring improvement)
Identify if practical measures could be taken for improving lifesaving responses in the future.
Identify what other factors (outside SLS control) may have contributed and what measures might prevent a repeat in the future
(i.e. signage at beach access).
Emotive Debrief
Introduction
Outline that this session and follow-up options for support are all about protecting our members and helping ensure they
continue to be involved in SLS and the impacts of the incident are minimised.
Outline that it is ok to ask for help and additional counselling sessions should be organised for anyone who thinks they might
benefit from it.
Trauma effects
Open a discussion on the effects a traumatic incident can have on all members (the young/inexperienced and old/experienced
alike).
Explain that everyone responds differently in the aftermath of a critical incident and that it is completely normal to be affected in
some way.
Explain that symptoms can fall into four areas: Behavioural, Physical, Cognitive and Emotional.
Some of the symptoms to watch for are:
Significant changes in an individual’s social and professional functioning
Marked symptoms of anxiety: restlessness, irritability, anger.
Avoidance behaviour (avoiding communication, activities, places and people associated with the incident).
Withdrawal from others: loss of motivation
Appearing like ‘being in a daze’
Appearing preoccupied or emotionally ‘flat’
Difficulties with concentration, attention and decision making
Teariness, fatigue
Exaggerated ‘startle response’
Increased alcohol consumption
Explain that these effects may not occur immediately but may occur in the weeks and months following the incident.
Support Available
1. Information pamphlets – hand these out to everyone
2. Website information www.accesseap.com.au
3. Free 24/7 Access Counselling Hotline 1800 818 728
4. Free Individual Counselling Session (locally) – member or their family can call 1800 818 728

Explain that through the WorkCover forms should be filled out today, to eliminate any paperwork should counselling be
requested in the future.
Discuss with the Club Captain or Club President for a follow up to occur with each member to ascertain how they are coping
with the situation.
Use below to list any members that you feel may need closer attention when a follow up occurs.
Member Identified For Further Follow Up
Critical Incident Debrief Checklist
‘Debrief Form’ completed in full
All personnel involved recorded with contact details– including those who may not be at debrief
‘Incident Log’ completed in full and copy attached
‘Patrol Log’ completed in full and copy attached
Any ‘Witness Statement Forms’ (individual) are completed attached
(for criminal incidents or incidents where serious member injury or public injury caused by SLS has occurred)
‘Notification of Injury/WorkCover Forms’ completed by all involved
(enables free counselling in the future if required)
‘Critical Incident Audit Form’ completed by Duty Officer
(Picture of beach/conditions taken if camera available)
Appropriate Branch Officers notified (Director of Lifesaving)
All paperwork and information forwarded to the Branch DOL within 48 hours.

Surf Life Saving NSW
CRITICAL INCIDENT AUDIT
INCIDENT DETAILS
Time: Day: Date:
______ / ______ / ______
Nature of Incident: SLSA IRD #:
Exact Location of Incident:
Land Manager:
PATIENT
Name:
Address:
♂ / ♀
Age:
ENVIRONMENTAL CONDITIONS
Tide (at time of incident):
Next Tide:
High / Low
Next Tide Time:
Swell Direction: Surf Height: Surf Conditions: Distance from water line:
Wind Direction: Wind Speed: Any active BOM Warnings:
Water Quality: Water Colour / Clarity: Were photos taken of the scene? (If so, how
long after the incident)
Period:
Dawn / Day / Dusk / Night
Temperature – actual:
Temperature – expected:
Further comments: (Raining, sunny, overcast, night time, floodlit, any other environmental aspects not covered.)

HAZARDS
Outline ALL hazards that were present at the time of the incident: (Describe location relevant to incident and the
possible effects it played in this incident.)
Rips
Gutters
Side currents
Sandbanks
River / creek
mouths
Pot holes
Reef
Marine
Creatures
Pollution
Drainage
Outlet
Headland
Rock
groynes
Submerged
rocks
Submerged
objects
Rock ledge
Suction Pipe
Drop Off
Powercraft
Surfcraft
ACCESS
Nearest Access to incident:
Informal / Formal
Describe Access: (Width; 4WD suitability;, clearly visible; base – board & chain,
sand, bitumen, stone, etc; )
Distance & direction from
incident:
Photos taken of access?
Beach Access / Emergency
Indicator Number:
Infrastructure / services adjacent to access way: (E.g: Car park for x cars, parking meters, toilets, drinking fountains,
BBQs, shelters, children’s playground, phone, café, kiosk, reserve, etc)
SIGNAGE
Signage on “street” side:
Yes / No
Fully describe – number of signs, what each sign indicates, condition of sign, comments
re visibility, obstructions, location, position, size of signs, suitability, etc
How many signs?

Photos taken of signage?
Signage on “beach” side:
Yes / No
Fully describe – number of signs, what each sign indicates, condition of sign, comments
re visibility, obstructions, location, position, size of signs, suitability, etc
How many signs?
Photos taken of signage?
RESCUE SERVICES
What statutory and volunteer rescue services attended?
Identify any issues with response (inc tasking, time, directions given, access, etc)
Nearest SLSC?
Any service on duty at that time? (If
yes, identify volunteer patrol, ALS,
APOLA)
Distance & direction from incident:
Describe exact location of red & yellow and blue flags: (inc distance between each flag and distance from SLSC or other
relevant location.)
PUBLIC LIFESAVING EQUIPMENT (PLE)
Describe any PLE in vicinity of the incident:
Was it utilized? (If so who by outline effectiveness, any access and other issues, etc. If not, why not?)
Does the PLE need to be replaced, different equipment required or does it need to be relocated to a more suitable
location?

HUMAN BEHAVIOUR
Describe any personal protective equipment the victim
had:
Was it utilized? (If so, outline effectiveness and other issues, etc.
If not, why not?)
Was the victim appropriately dressed for the activity?
Describe further if required.
Is there any evidence of the victim being affected by drugs or
alcohol? Describe further if required.
Is it possible that the victim suffered a medical
condition that contributed to this incident? Describe
further if required.
Is it possible that the victim committed suicide or a criminal
act contributed to this incident? Describe further if required.

SITE PLAN (indicate northerly direction)

OTHER IMPORTANT INFORMATION
RECOMMENDATIONS

AUDIT UNDERTAKEN
Time / Date:
Name and Signature:
Any further action to be undertaken:

SURF LIFE SAVING NEW SOUTH WALES
NOTIFICATION OF INJURY FORM
This form is to be completed when a volunteer suffers an injury or illness where compensation is or may be payable
under the Workers Compensation Emergency and Rescue Act 1987. This form must be submitted within 48 hours
upon notification of intent to claim.
Procedure
In order to process a workers compensation claim quickly, attention should be given to the following:
1. The injured club member should immediately notify their supervisor in the event of any injury or illness. It is vital
that this injury/illness is entered into the logbook and then into the Incident Reporting Database (IRD) by a
nominated club authority.
2. Complete this Notification of Injury Form (if claiming workers compensation benefits) and fax it to WorkCover on 02
9287 4828.
3. If your injury has or will result in you being away from your paid employment for 7 days or greater, you will need to
contact WorkCover immediately (1800 221 960) to advise of your injury;
4. If required by WorkCover NSW, the injured club member (or guardian if under 18) is to complete the Workers
Compensation Claim Form.
Scope of Cover
The Cover under WorkCover is limited to compensation payable as described in the Workers compensation (Bush Fire,
Emergency and Rescue Services) Act 1987, whilst the member is acting in their capacity as a Surf Lifesaver. The cover
extends to official duties anywhere in Australia. All Surf Lifesaving activities may need to be verified by proof of entry to
competition, patrol roster, volunteer roster, patrol log book, IRB log book, radio log book etc. Training and competition
can only be at authorised and organised sessions. Members who compete in elite events where prize money is paid or
professional sportspersons or competitors, who compete in events not under the control of the SLSA, may need to take
separate insurance/workers compensation.
WorkCover may require the claimant to attend a medical examination by a doctor nominated by the Authority.
Dependent on claim complexity, additional information may be sought by WorkCover.
Approval for any medical treatment is to be obtained from WorkCover NSW prior to the commencement of treatment,
unless the treatment has been provided in the case of an emergency.
Who was injured?
Title: Mr □ Mrs □ Ms □ Miss □ Other □ Male □ Female □
Surname:
Given names:
Street No. and Name:
Suburb/Town:
Date of Birth:
State: Post Code: Phone:
Details of Injury
When did your injury occur? Date:
Time:
What part(s) of your body were affected from your injury/condition (i.e. left/right broken wrist)?

Type of accident
□ Sprain/Strain □ Dental □ Fracture/Dislocation
□ Broken bone □ Spinal Injury □ Laceration
□ Other, please specify
What happened to cause your injury/condition?
What caused the injury?
□ IRB □ Surf Ski □ Surf Board □ Surf Boat
□ Patrol duties □ Competing □ Training □ Rescue
□ Other, please specify
Membership Details
Club status (i.e. member, Club Captain, Patrol Captain):
Name of Club/Branch:
Medical Treatment
Did you receive any medical treatment? □ Yes □ No
Are you currently having medical treatment for this injury/illness? □ Yes □ No
If yes, please provide details of the doctor and/or hospital you obtained/is obtaining treatment from:
Doctor/Hospital:
Address:
Phone: Medical Certificate attached? □ Yes □ No
Time Lost
Have you lost any time from your paid employment as a result of this injury? □ Yes □ No
If yes, who is your employer?
If yes, what is your occupation?
Where to get help with this form: If you need assistance in completing this form, you can contact the Surf Life Saving
NSW’s Awards and WorkCover Officer on 6550 1132.
Declaration
I have read the information provided in this form. I declare that the information that I have supplied in this form, and any attachments to this form, is
true and correct to the best of my knowledge. I understand that the making of a false or misleading notification or false or misleading statement in
support of the notification in punishable by law and that I may be prosecuted.
I authorise and consent to the collection, disclosure and release of any personal and health information in connection with an injury/condition to which
the notification relates by the WorkCover Authority of NSW or my volunteer organisation to each other, or to any person who provides a medical
service or hospital service to me in connection with an injury/condition to which this notification relates. I understand that if this notification results in
my receiving weekly compensation payments, I am required to notify whoever is paying my benefits if I commence employment with some other
person or in my own business, or if any change in my employment that affects my earnings, and that failure to do so is an offence. I consent to the
WorkCover Authority of NSW using the information collected in connection with my notification for the purposes of research about workers
compensation, workplace injury management and occupational health and safety.
Signature:
Date:

Guardian (if under 18): Name: Signature:
Witness (Club Official): Name: Signature:
Witness Contact Number:
In circumstances where the injured member is unable to complete this form:
Name of person completing this form:
Position of person:
Address of Club/Branch:
Contact Number:
Additional information and the completion of a Workers Compensation Claim Form may be required by WorkCover NSW
A copy of this form should be retained for your records
This form can be sent directly to WorkCover NSW, Locked Bag 2906, Lisarow, NSW, 2252 or via Fax to 02 9287 4828

SURF LIFE SAVING NEW SOUTH
WALES
WORKERS COMPENSATION CLAIM FORM
This form is to be completed if you are a volunteer and you want to claim workers compensation for an injury or illness
under the Workers Compensation Emergency and Rescue Act 1987, or you may have been asked by WorkCover to
complete the claim form.
Procedure
In order to process a workers compensation claim quickly, attention should be given to the following:
5. The injured club member should immediately notify their supervisor in the event of any injury or illness. It is
vital that this injury/illness is entered into the logbook and then into the Incident Reporting Database (IRD)
by a nominated club authority;
6. Complete the Notification of Injury Form and fax it to WorkCover on 02 9287 4828;
7. If requested by WorkCover NSW, the injured club member (or guardian if under 18) is to complete this
Workers Compensation Claim Form. This can be done with the assistance of the Club Safety Officer (if
required) and be signed off by an authorised club official. All sections of this form must be completed by all
parties concerned. If answers do not fit in the space provided, please attach additional pages for your
information;
8. If your injury has or will result in you being away from your paid employment for 7 days or greater, you will
need to contact WorkCover immediately (1800 221 960) to advise of your injury;
9. Provide any documents required to assess the claim (see below);
10. The Workers Compensation Claim Form must be faxed to WorkCover NSW (02 9287 4828) within 48 hours
(recommended time frame);
11. A copy of this form should be retained for your records.
Documentation Required
If you are, or there is a possibility that you will be claiming weekly compensation benefits because you will be
losing wages from your paid employment, you will need to:
Provide WorkCover Medical Certificates for your injury that states the dates you are not able to work and that
your volunteer duties were a substantial contributing factor to your injury. All medical certificates must state
a precise medical diagnosis;
Your employer will need to complete a Statement of Earnings form;
For WorkCover to assess a fair and reasonable weekly entitlement for self employed volunteers, it is required
that self employed volunteers provide an Employment (Tax) Declaration as well as a WorkCover Medical
Certificate. Please refer to WorkCover’s policy “Weekly Compensation for Self Employed Volunteers” which
can be downloaded from the SLSNSW website;
If you are claiming compensation only for the cost of medical or hospital and rehabilitation costs you will need
to attach your tax invoices and receipts for these services.

Scope of Cover
The Cover under WorkCover is limited to compensation payable as described in the Workers compensation (Bush
Fire, Emergency and Rescue Services) Act 1987, whilst the member is acting in their capacity as a Surf Lifesaver.
The cover extends to official duties anywhere in Australia. All Surf Lifesaving activities may need to be verified by
proof of entry to competition, patrol roster, volunteer roster, patrol log book, IRB log book, radio log book etc.
Training and competition can only be at authorised and organised sessions. Members who compete in elite events
where prize money is paid or professional sportspersons or competitors, who compete in events not under the
control of the SLSA, may need to take separate insurance/workers compensation.
WorkCover may require the claimant to attend a medical examination by a doctor nominated by the Authority.
Dependent on claim complexity, additional information may be sought by WorkCover.
Approval for any medical treatment is to be obtained from WorkCover prior to the commencement of treatment,
unless the treatment has been provided in the case of an emergency.
Where to get help with this form
If you need assistance in completing this form, you can contact the Surf Life Saving NSW’s Awards and WorkCover
Officer on 6550 1132.

Section 1
What is your full name?
Title: Mr □ Mrs □ Ms □ Miss □ Other □ Male □ Female □
Surname:
Given names:
What is your country of birth?
Where do you live?
Street No. and Name:
Suburb/Town:
State:
Postal Address (if different from above):
Post Code:
Date of Birth:
How can we contact you?
Telephone (H):
(W):
E-mail address:
(Mobile):
Do you need an interpreter? Yes □ No □ What language?
Surf Life Saving NSW Details
Name of the club that you belong to:
Club Status (i.e. member, Club Captain):
Have you previously completed a Notification of Injury Form for this injury? Yes □ No □
About your Injury
When did your injury occur? Date (dd/mm/yyyy): Time (am/pm):
Have you needed to take time off from paid employment? Yes □ No □ N/A □
If yes, when did you stop working? Date (dd/mm/yyyy):
Time (am/pm):
If yes, when did you return to work? Date (dd/mm/yyyy): Time (am/pm):
If yes, your employer will need to complete a Statement of Earnings form.
What part(s) of your body were affected from your injury/condition (i.e. left/right broken wrist)?

What happened to cause your injury/condition?
Were you injured:
□
During the course of participating in your volunteer duties;
□
□
On a break while volunteering;
Other, please give details.
What is the address where you were injured?
When and where did you first seek medical treatment for this injury/condition?
Date (dd/mm/yyyy):
Time (am/pm):
Name of doctor, medical practice or hospital:
Address:
Telephone number: Medical Certificate attached? Yes □ No
□
Have you been referred to a specialist or for any diagnostic tests for your injury/condition?
Yes □ No □ If yes, please provide details:
Name of specialist:
Telephone Number:
Nature of referral:
If you have been referred to more than one specialist, please attach details (x-rays etc.)

Have you undertaken any of the following treatments for your injury/condition?
□ Hospital treatment □ Chiropractor □ Physiotherapy
□ Counselling □ Pharmaceutical □ Other (Please give
details):
Have you ever had similar symptoms, injury/condition and body parts affected?
Have you ever had a previous workers compensation claim? Yes □ No □
If yes, please provide details:
Injury/condition
Year claimed
Claim Number
Name of insurer
Name of employer or volunteer association
Volunteer Declaration:
I understand that if this claim results in my receiving weekly compensation payments, I am required to notify
whoever is paying my benefits if I commence employment with some other person or in my own business, or if any
change in my employment that affects my earnings, and that failure to do so is an offence. I consent to the
WorkCover Authority of NSW using the information collected in connection with my claim for the purposes of
research about workers compensation, workplace injury management and occupational health and safety.
I confirm that the activities I was engaged in at the time of this injury, were volunteer activities for my association.
This activity was undertaken with the consent of or under the authority and supervision of a person authorised by
my volunteer association to give that consent and/or supervision. My services were given without remuneration
or reward, voluntarily and without obligation.
Volunteer signature:
Date:
Section 2 Volunteer Organisation to Complete
Name of Branch/Club:
Name of club official:
Position of club official:
Telephone number of Official:
Date and time of the injury: Date (dd/mm/yyyy): Time (am/pm):

Name of injured volunteer:
Describe the type of injury the volunteer suffered:
Describe what activities the volunteer was involved in when the injury occurred:
□
□
I confirm that the above named volunteer was under my control and/or instruction as a volunteer at the
time of this injury.
I confirm that the above name volunteer was NOT under my control and/or instruction as a volunteer at
the time of this injury.
Declaration
I have read the information provided on this form and any attachments. I declare that the information that I have
supplied in this form and any attachments to this form, is true and correct and that no information has been
suppressed or omitted from this report to the best of my knowledge. I understand that the making of a false or
misleading statement concerning a claim is punishable by law and that I may be prosecuted.
I confirm that the activities the claimant was engaged in at the time of the injury were volunteer activities for
his/her association and these activities were undertaken with the consent of or under the authority and
supervision of a person authorised by the volunteer association to give that consent and/or supervision. The
volunteer’s services were given without remuneration or reward, voluntarily and without obligation.
Signature:
Title:
Date:
SLSNSW OFFICE USE: Received Claim Date: __ / __ / __ Submitted to WorkCover Date: __ / __ / __ Claim No:
_____________

Details of Witness
SURF LIFE SAVING
WITNESS STATEMENT
Last Name
First name
Address
Suburb State P/code
Contact Phone ( ) Mobile
Date of Birth ______
Email:___________
Witness Statement Completion Instructions
PLEASE READ THE FOLLOWING NOTES CAREFULLY BEFORE COMMENCING
YOUR STATEMENT
‣ Provide lead up information of events that occurred prior to the actual incident,
‣ Include a description of weather, surf conditions etc
‣ Provide as much detail as possible about the actual incident including
distances, times, speed, size etc
‣ Write only about what YOU saw and heard
‣ Conversation should be in first person.
‣ If you are unable to recall first person conversation you may still record the
conversation to be the best of your recollection.
‣ Include any qualifications and experience you may have
Details of witness statement
This statement made by me accurately sets out the evidence that I would be prepared,
if necessary to give in court as a witness. The statement is true to the best of my
knowledge and belief and I make it knowing that, if it is tendered in evidence, I will be
liable to prosecution if I have wilfully stated in it anything that I know to be false or do
not believe to be true.

Person Making Statement
Name:
Signed
Date
Person Witnessing Signature
Name:
Signed
Date
Details of witness statement
This statement made by me accurately sets out the evidence that I would be prepared,
if necessary to give in court as a witness. The statement is true to the best of my
knowledge and belief and I make it knowing that, if it is tendered in evidence, I will be
liable to prosecution if I have wilfully stated in it anything that I know to be false or do
not believe to be true.

Person Making Statement
Name:
Signed
Date
Person Witnessing Signature
Name:
Signed
Date

Please use this page to draw any pictures about the incident (if needed)
Person Making Statement
Name:
Signed
Date
Person Witnessing Signature
Name:
Signed
Date