Report Form for Accidents, Incidents and Near Misses
This form should be filled in as close to the incident date as possible by a member of ISA staff.  If the incident was witnessed by a visitor or student, they should find a relevant staff member to fill it in on their behalf. Information will be sent to the Head of School, Principals, Assistant Principals, Health and Safety Officer and School nurse.  
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Notification of Incident - please select area of school in order to notify relevant staff (in addition to Head of School, Health & Safety Officer, Facilities Manager & School Nurse)
Full Name of incident reporter *
Email address of incident reporter *
Full name of other witness (if possible) and their status (staff, ISA student, visiting student, parent, other adult)
Contact details of other witness (if possible) and their status (staff, ISA student, visiting student, parent, other adult)
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Type of Incident (tick all that are relevant) *
Required
Full name of victim *
Contact details of victim (email, telephone, or Grade level if an ISA student) *
Status of victim *
Full name of other victims (if needed)
Contact details of other victims (if needed) - email, telephone or Grade level.  
Status of other victims (if needed) - see categories above
Location of incident
Explanation of incident  (including what caused it, those involved, and damage done) *
What follow up occurred? (eg first aid given and who was informed) *
Is any further action recommended? (This may include repairs or reporting it to other authorities etc)
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