"Incident Report Form - Child Safe Standards"

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INCIDENT/ACCIDENT REPORT FORM – sample
<Name of Faith Community Organisation>
SECTION A – The Details
DATE (of report)
WRITTEN BY
Date of incident:
PERSON(s) INVOLVED
Personnel informed:
Senior Ministry Leader
Ministry Coordinator
Pastoral Care Leader
Safe Child Safe Standards Representative
Safeguarding Officer
Other
Type of Incident
injury
behaviour
disclosure*
property damage
environment/safety
other
(specify)
*NB: If disclosure of abuse – please also complete the Risk of Significant Harm and
Reporting Concerns Forms
SECTION B – The Incident
DETAILS OF INCIDENT
www.childsafestandards.org.au
Standard 5
INCIDENT/ACCIDENT REPORT FORM – sample
<Name of Faith Community Organisation>
SECTION A – The Details
DATE (of report)
WRITTEN BY
Date of incident:
PERSON(s) INVOLVED
Personnel informed:
Senior Ministry Leader
Ministry Coordinator
Pastoral Care Leader
Safe Child Safe Standards Representative
Safeguarding Officer
Other
Type of Incident
injury
behaviour
disclosure*
property damage
environment/safety
other
(specify)
*NB: If disclosure of abuse – please also complete the Risk of Significant Harm and
Reporting Concerns Forms
SECTION B – The Incident
DETAILS OF INCIDENT
www.childsafestandards.org.au
Standard 5
ACTION TAKEN
OUTCOMES (if known)
SECTION C – Follow up/Analysis
Follow up comments:
The type of incident is:
first report
subsequent report
Have appropriate steps been taken?
Yes
No
If No (to either of the above), what needs to be done?
Print Name: _________________
Signed:
__________________
Reported to (Personnel informed)
Print Name: __________________
Signed:
__________________
Standard 5
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