Incident Reporting Form

Centre Name

SPACE and Babies Can Play (External Sites)

Date / Time of Incident

Date

Time

Kaimahi Name

First

Last

Kaimahi Email

Type of Incident

Near Miss – no harm was caused but it could have
Incident – First Aid Only (no investigation is required)
Serious Incident – more than First Aid, needing a GP, dentist (these events should be reported to RSL & RM immediately)
Serious Harm – Notifiable injury, treated as inpatient, surgery required (reported to RSL & RM immediately)
Notifiable Illness

Detail Email involve

Illness

Appendix 2: Infectious diseases for criterion HS26 – * Centre Notifiable / ** Notifiable Disease

Did the incident involve damage to the Centre property or an asset?

Please describe. E.g., broken decking, failed door hinge, damaged fence post etc. Or leave blank.

Incident Detail

As other was specified, please provide detail

e.g. allergy / anaphylactic reaction, choking, strangulation, oral contact with hazardous substance, etc.

Additional Information

Please use this field to add any other useful information, e.g. child was a visitor, incident was an adult, etc.