Critical Incident Report Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Reported By (Name) *Role *StaffStudentOther, please specifySpecify the RoleImmediate Actions Taken *First AidEmergency Services CalledIncident ContainedNoneVictimProvide Full Name, Student ID / Staff Role, and Contact Info for all VictimsWitnessProvide Full Name, Student ID / Staff Role, and Contact Info for all WitnessesResponderProvide Full Name, Student ID / Staff Role, and Contact Info for all RespondersIncident Type (Tick all that apply) *Death or serious injuryPhysical or sexual assaultMental health crisis (e.g., suicide attempt)Threat of harm / violenceDrug or alcohol incidentMissing personNatural disasterFire or explosionOther, please specifySpecify the Incident TypePlease describe the event in detail, including sequence of events, observed behaviours, and any contributing factors: *First Aid AdministeredFirst Aid AdministeredPerformed byNotesEmergency Services ContactedEmergency Services ContactedPerformed by (copy)Notes (copy)Family / Emergency Contact NotifiedFamily / Emergency Contact NotifiedPerformed by (copy) (copy)Notes (copy) (copy)Immediate Counselling ProvidedImmediate Counselling ProvidedPerformed by (copy) (copy) (copy)Notes (copy) (copy) (copy)Evacuation ConductedEvacuation ConductedPerformed by (copy) (copy) (copy) (copy)Notes (copy) (copy) (copy) (copy)Site SecuredSite SecuredPerformed by (copy) (copy) (copy) (copy) (copy)Notes (copy) (copy) (copy) (copy) (copy)Single Line TextCheckbox ItemsYesSingle Line TextCheckbox Items (copy)YesSingle Line TextCheckbox Items (copy) (copy)YesSingle Line TextCheckbox Items (copy) (copy) (copy)YesSingle Line TextCheckbox Items (copy) (copy) (copy) (copy)YesReport Received By ((Compliance Manager Name)) *Secure File LocationIncident NumberRetention ScheduleMinimum 2 years post-enrolmentSubmit
