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Report an Incident or
Near-Miss Incident
Report an Incident General
Women's College
2023-08-18T12:12:17+10:00
Report an Incident or Near-Miss Incident
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Please fill in all fields in the relevant parts of the form (depending on the type of incident). Once completed click submit. The form will be sent to relevant staff.
Reporter's information
Please include the details for the person who is completing the form in this section.
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Your email address
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Are you a Staff member, Resident or Guest?
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Information about the incident
What type of Incident Occured?
*
Click to select
Injury or Illness
Security Incident
Property Damage
Near Miss Incident
Hazard
Date Incident Occured?
*
DD slash MM slash YYYY
Time Incident Occured?
*
Hours
:
Minutes
AM
PM
AM/PM
Please list the names of the people involved in the incident
Name of Witness
First
Last
Phone number of Witness
Brief Description of Incident / Hazard
*
Incident Details
Injury or Illness Details
Immediate Treatment provided (Select all that Apply)
First Aid
Ambulance
Hospital
Doctor (GP)
NIL treatment
Describe Injury or Illness, Body Location and How it happened
*
Damage Details (car, property etc)
Property / Equipment / Vehicle Details Damages
Nature of Security Breach
Security Breach Details
Location of Security Breach
Nature of Damage
Near Miss Incident Details
A near-miss is a potential hazard or incident in which no property was damaged, and no personal injury was sustained, but where, given a slight shift in time or position, damage or injury easily could have occurred. Near misses also may be referred to as close calls, near accidents, or injury-free events. For the sake of a safe environment, The Women’s College asks that all members of the community report and correct any of these potential hazards immediately. Please use this form to report near-misses and assist us in preventing future incidents and making the College a safer place.
Type of near-miss
Near-miss
Safety concern
Safety idea/suggestion
Other
Type of concern
Unsafe act
Unsafe condition of area
Unsafe condition of equipment
Unsafe use of equipment
Safety policy violation
Other
Describe the potential incident/hazard/concern and possible outcome (be detailed)
Were safety procedures violated? Please describe
Incident site inspection: why was an unsafe act committed, or why was the unsafe condition present?
What are your recommendations/steps to take to prevent a similar incident?
Hazard Details
Describe the Hazard
Estimate Risk (High to Low immediate risk to cause an incident)
*
Determine Risk of hazard based on likelihood of impact on person, property etc if hazard is not attended to immediately.
High Risk - attend to urgently
Medium Risk - needs seeing to pretty soon
Low Risk - no immediate risk but should be attended to
Your Signature
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