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Documenting and Reporting Incidents

"*" indicates required fields

DOCUMENTING AND REPORTING INCIDENTS

Educator*

First Name Last Name

Educator Email*

Phone*

Parent/ Guardian*

First Name Last Name

Parent/ Guardian Email*

Submitted By*

This field is hidden when viewing the form

Date Form Submitted*

I am hidden because it is irrelevant to have me be pickable. Code on the backend forces my day to be equal to the current date. I am simply holding this info. Think of me as not here.

Date of Incident*

Time of Incident*

Address of Incident*

Street Address City State

Type of Incident*

Name of Child / Person or Persons impacted by the incident*

Names of all witnesses present at the time of the incident*

Include their relationship to the child: (e.g. Educator, mother, by stander.......Note: bystander contact details if available)

Circumstances leading to the incident/injury/trauma/illness, including any apparent symptoms*

Details of incident/injury/trauma/illness*

Details of action taken by Educator (including first aid, administration of medication, etc.)*

Details of WHO was notified, including what TIME and METHOD of communication*

(e.g. Police via phone at 1.50pm, Mother via phone at 2pm, IHC Service via phone at 2.05pm)

Did emergency services attend? Was medical attention sought from a medical practitioner / hospital? (If Yes, please provide details below)*

Have any steps been taken to prevent or minimise this type of incident in the future? If yes, provide details*

What actions would you like the IHC service provider to take?*

(e.g. support compliance with safety protocols from Family / Educator)

Please upload any supporting evidence or documentation here

Drop files here or

Accepted file types: jpg, png, pdf, docx, doc, Max. file size: 5 MB.

By submitting this form I consent to ALHCA providing information to a third party such as the Support Agency, Department of Education, Child Safety to resolve and manage the issue.

I acknowledge that I am also required to speak directly with the ALHCA, the IHC Service via phone - immediately if possible, or once the child/situation is safe, or by the end of the shift at the very latest, but definitely within 24 hours so that all regulatory obligations can be met.

Signed By*

Please include BOTH your First & Last Name

Documenting and Reporting Incidents