MBC - INCIDENT REPORT FORM

Details of Person Involved in Incident

First Name *

Date of Birth

Last Name *

Age:

Description of Incident

Date/Time: *

Location: *

Describe the incident: *

Does this incident involve injury to a person/s: *

Yes

If yes, please complete the Injured Person/s section below.

Activity Information Relevant to the Incident

Name of event/group:

List those acting in a position of responsibility for this event/group:

First Name: *

Last Name: *

First Name:

Last Name:

Is this a MBC regular event? *

Yes

Is this a one-off event/affiliation? *

Yes

Were any emergency services required as a result of the incident?

Yes

Has the issue been escalated (where required)?

Yes

Is the incident a 'Serious Event' notifiable to Worksafe?

Yes

Unsure

If 'YES', has this been done?

Yes

Unsure

Details of Injury Incident

Please only fill in this section if an injury occured.

What area/s of the person's body was injured?

What was the person doing when the injury happened?

Any factors pertinent to the incident? (eg weather conditions, broken or damaged equipment, time of incident etc):

How did the person respond after the incident?

Was first aid given or some other action taken?

Yes

If 'Yes', what action was taken?:

By whom?

Name(s) of any witnesses to the incident:

Witness 1: *

Witness 2:

Witness 3:

Witness 4:

Specific to Injury Incidents involving Children Under 18

Notification to parents / guardians:

Who made the notification?:

Name of parent/guardian notified:

How did they respond?:

Was/is any corrective action required as a result of this incident?

Yes

If 'YES', please provide details

Details of Person Reporting Incident

Name of person/s completing this form: *

Phone Number

Email Address

Signature: *

Date: *

Upon completion, this form needs to be forwarded to the head of the ministry. In such cases as serious injury / event / or corrective action being required, this form should then be forwarded to the Leadership Council as soon as practicable.