This form is designed to collect information that occurs when an accident or near miss occurs during a Roncalli sporting activity that may involve staff, students or members of our community.
Date of Injury/Incident *
Your answer
Time of Injury/Incident *
Where did Injury/Incident occur *
Your answer
Name of person completing this report: *
Your answer
Name of person affected: *
Your answer
What occured: *
Your answer
Details of injury *
Action taken to address the injury: *
Your answer
What do you think is the likelihood of this incident/ injury occurring again? *
How would you rate the severity of this incident? *
See image below for descriptions
Incident Severity Scale
Ignore the Department of Labour (DOL) and National Incident Database references
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