Critical Incident Debrief Flow-Chart - Surf Life Saving NSW

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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.)
Page 2 and 3: ACKNOWLEDGEMENTS This document is i
Page 4 and 5: Overview Purpose It is the aim of t
Page 6 and 7: Supporting Resources and Counsellin
Page 8 and 9: CRITICAL INCIDENT DEBRIEF LOG Name
Page 11 and 12: Involvement Summary Who did what? (
Page 13 and 14: Explain that through the WorkCover
Page 15 and 16: HAZARDS Outline ALL hazards that we
Page 17 and 18: HUMAN BEHAVIOUR Describe any person
Page 19 and 20: OTHER IMPORTANT INFORMATION RECOMME
Page 21 and 22: SURF LIFE SAVING NEW SOUTH WALES NO
Page 23 and 24: Guardian (if under 18): Name: Signa
Page 25: Scope of Cover The Cover under Work
Page 29 and 30: Name of injured volunteer: Describe
Page 31 and 32: Person Making Statement Name: Signe
Page 33: Please use this page to draw any pi

Critical Incident Debrief Flow-Chart - Surf Life Saving NSW

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