Critical Incident Report Form

1. Incident Overview

Date / Time of Incident

Date

Time

Location of Incident

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Reported By (Name)

Role

Staff
Student
Other, please specify

Specify the Role

Contact Number

Immediate Actions Taken

First Aid
Emergency Services Called
Incident Contained
None

2. Individuals Involved

Victim

Provide Full Name, Student ID / Staff Role, and Contact Info for all Victims

Witness

Provide Full Name, Student ID / Staff Role, and Contact Info for all Witnesses

Responder

Provide Full Name, Student ID / Staff Role, and Contact Info for all Responders

3. Incident Type

Incident Type (Tick all that apply)

Specify the Incident Type

4. Incident Description

Please describe the event in detail, including sequence of events, observed behaviours, and any contributing factors:

5. Initial Support and Safety Actions

Action

Performed By

Notes

Layout

First Aid Administered

First Aid Administered

Performed by

Notes

Layout

Emergency Services Contacted

Emergency Services Contacted

Performed by (copy)

Notes (copy)

Layout

Family / Emergency Contact Notified

Family / Emergency Contact Notified

Performed by (copy) (copy)

Notes (copy) (copy)

Layout

Immediate Counselling Provided

Immediate Counselling Provided

Performed by (copy) (copy) (copy)

Notes (copy) (copy) (copy)

Layout

Evacuation Conducted

Evacuation Conducted

Performed by (copy) (copy) (copy) (copy)

Notes (copy) (copy) (copy) (copy)

Layout

Site Secured

Site Secured

Performed by (copy) (copy) (copy) (copy) (copy)

Notes (copy) (copy) (copy) (copy) (copy)

6. Follow-Up Plan

Task

Assigned To

Due Date

Completed

Layout

Referral to external support services

Single Line Text

Due date

Checkbox Items

Yes

Layout (copy)

Academic adjustments required

Single Line Text

Due date (copy)

Checkbox Items (copy)

Yes

Layout (copy) (copy)

Family engagement or debriefing

Single Line Text

Due date (copy) (copy)

Checkbox Items (copy) (copy)

Yes

Layout (copy) (copy) (copy)

ASQA Notification (if required)

Single Line Text

Due date (copy) (copy) (copy)

Checkbox Items (copy) (copy) (copy)

Yes

Layout (copy) (copy) (copy) (copy)

Add to Continuous Improvement Register

Single Line Text

Due date (copy) (copy) (copy) (copy)

Checkbox Items (copy) (copy) (copy) (copy)

Yes

7. Compliance and Recordkeeping

Report Received By ((Compliance Manager Name))

Date Received

Secure File Location

Incident Number

Retention Schedule

Minimum 2 years post-enrolment

Date

Critical Incident Report Form