Incident or Accident Report | Queen Mode Academy

Effective date: TBC
Version: TBC
Policy owner: TBC

Immediate danger: call 000

This form does not replace emergency, safeguarding or mandatory reporting.

Incident details

Date required

Time required

24-hour time, e.g. 16:45.

Location required

Queen(s) involved

Required when applicable. Use names as recorded in enrolment.

Staff and Coach required

Type required

What happened

Provide an objective description. Record what was seen, heard and done. Do not speculate.

Objective description required

Response and notification

Injury or symptoms

First aid or emergency response

Ambulance/medical assistance

Yes

Parent or Guardian notified

Yes

Notification time

This and the following fields apply only if you chose “Yes” above.

Person notified

Notified by

Program lead notified

Yes

Time program lead notified

Only if you chose “Yes” above.

Immediate controls or changes made

Witnesses and follow-up

If safeguarding escalation is Yes or Unsure, follow the Child Safety & Wellbeing and Emergency & Incident Response procedures immediately. Do not wait for this report.

Witness names and contact information

Further action required

Safeguarding escalation required

Yes

Unsure

External authority notified

Reference

Time notified

Attachment reference

Upload is unavailable without a backend; note the file name or location.

Completion

Completed by required

Role required

Signature

Date required

Program Lead Review

Reviewer

Reviewer signature

Review date

I confirm that this report is factual to the best of my knowledge and that required immediate safety actions and notifications have been completed or escalated. required

Signature lines are printed for signing by hand.

Print and save

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Direct email: maddison@queenmode.com.au

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