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INCIDENT REPORT
THIS REPORT WILL BE SENT TO:
safety@c3carlingford.orh.au
& Pastor Russell Carroll
Date and time of Incident
*
Day
Month
Year
Time
:
Hours
Minutes
AM
Time of Writing of this report
Time
:
Hours
Minutes
AM
Venue
Location at Venue
Description of incident (please include any information about the lead-up to the incident or following the incident that could help us prevent similar incidents in the future):
Names and contacts of those involved:
Immediate Action taken:
Medical attention required:
Yes
No
Medical attention provided by:
Ambulance Called:
Yes
No
Time ambulance called:
Time
:
Hours
Minutes
AM
Time ambulance arrived:
Time
:
Hours
Minutes
AM
Transported to hospital:
Yes
No
Transported to hospital by:
Hospital taken to:
Family advised:
Yes
No
Critical Incident Team notified:
Yes
No
Which member of the Critical Incident Team was notified:
C3 Wentworthville senior leader notified:
Yes
No
Which senior leader was notified:
Date and time of latest information about this incident:
Day
Month
Year
Time
:
Hours
Minutes
AM
Latest status of incident:
Would you recommend any further follow-up, action or review that you were not able to complete:
Yes
No
Details of recommendation:
First name
Last name
Position:
Submit
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