SuperPuppy3470 Incident, Injury, Trauma and Illness Record Details of person…Incident, Injury, Trauma and Illness Record
Details of person completing this record
Name: …………………………………………………………… Position/role: ……………………………………………..
Date and time record was made ……../……/……….
Signature: ……………………………………………………..
Child details
Child’s full name: ……………………………………………………………………………………………………………
Date of birth: ……../……../…….. Age: ……………… Gender : Male Female
Incident details
Incident date: ……../……../…….. Time: …….. am/pm
Location:?
Name of witness: ……………………………………………………………………………………………………………………………
Witness signature: …………………………………………………………………………………………………. Date: …./…./…..
General activity at the time of incident/injury/trauma/illness:
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Cause of injury/trauma: Ava walked to the end of the balance beam and attempted to climb over a frame at the end her left foot slipped and she fell knocking her chin on the a frame. This left a shallow cut about 1 cm long on the bottom of her chin. This cut was bleeding
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Circumstances surrounding any illness, including apparent symptoms:
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Circumstances if child appeared to be missing or otherwise unaccounted for (incl duration, who found child etc):
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Circumstances if child appeared to have been taken or removed from service or was locked in/out of service (incl who took the child, duration):
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Little.ly SD Incident, Injury, Illness and Accident Record V1.0 (ID 184046)
© 2020 Eduworks Resources????????????????Page 13
Nature of injury/trauma/illness:
Indicate on diagram the part of body affected?Abrasion / Scrape
? Allergic reaction (not anaphylaxis
? Amputation
? Anaphylaxis
? Asthma / respiratory
? Bite wound
? Bruise
? Broken bone / fracture / dislocation
? Burn / sunburn
? Choking
? Concussion
? Crush / jam
? Cut / open wound
? Drowning (non-fatal)
? Electric shock
? Eye injury
? Infectious disease (incl gastrointestinal)
? High temperature
? Ingestion / inhalation / insertion
? Internal injury / Infection
? Poisoning
? Rash
? Respiratory
? Seizure /unconscious/ convulsion
? Sprain / swelling
? Stabbing / piercing
? Tooth
? Venomous bite/sting
? Other (please specify)
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Little.ly SD Injury & Illness form V1.0 (ID 184046)
© 2020 Eduworks Resources????????????????Page 13
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Action Taken
Details of action taken (including first aid, administration of medication etc): …………………………………………………………………………………………………………………………………………………..
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Did emergency services attend?: Yes / No
Was medical attention sought from a registered practitioner / hospital?: Yes / No
If yes to either of the above, provide details:
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Have any steps been taken to prevent or minimise this type of incident in the future?:
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Notifications (including attempted notifications)
Parent/guardian: ………………………………………….Time: …… am/pm Date:
Director/educator/coordinator: ……………………………………….. ?Time: ……am/pm Date:
Other agency (if applicable): …………………………………………..?Time: ………….. .am/pm ?Date: ……/……../……
Regulatory authority (if applicable): …………………………………?Time: …………….am/pm Date: ……../……../….
Parental acknowledgement:
I………………………………………………………………………………………………………………………………………………………
(name of parent/guardian)
have been notified of my child’s incident/injury/trauma/illness.
(Please circle)
Signature: ………………………………………………………………………………………..?Date: …./……../……..
Additional notes:
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……………………………………………………………………..Arts & HumanitiesEnglish
