CHC30113 Certificate III: Incident Reporting in Early Childhood

This assignment provides a template for an incident report form designed for use in early childhood education and care settings, specifically aligned with the CHC30113 Certificate III curriculum. The form includes sections for detailing center information, incident specifics (type, injuries, damage), responses taken (first aid, medical treatment, assistance sought), and witness accounts. It emphasizes the importance of clear, precise, and factual reporting, including location details and contributing factors. The form also includes a section for the reporter's information and signature to verify the accuracy of the report. Desklib offers a variety of educational resources, including solved assignments and past papers, to support students in their academic pursuits.

Incident Report Form
1. Centre details
Location: Please Insert
Director: Please Insert Contact phone:
Setting: Please Insert
2. Incident details
Day: Please Insert Date: Please Insert Time: Please Insert
Report completed by: Please Insert
3. Type of incident (indicate which is applicable)
Personal injury Staff Customer Child
Name of person injured: Please Insert
Part of Body Injured (if relevant):
Nature of injury sustained:
Abrasions, scrapes
Bite
Broken bone/fracture
Bruise
Burn
Concussion
Cut
Rash
Sprain
Swelling
Other (please specify)
Approximate size/colour of injury:
Damage to goods (please specify):
Sparkling Stars Incident Report Form V1.0 – Produced 30 August 2024
Page 1 of 3
© Commonwealth of Australia 2012, Licensed under Creative Commons Attribution-ShareAlike 3.0 Australia License

Please Insert
Assault Staff Customer Other
(please specify):
Vandalism
Robbery/break-in (also complete security incident report form)
Equipment failure/damage (please specify):
Please Insert
4. Response to incident (indicate which is applicable)
First aid treatment administered (please specify what/by whom etc):
Please Insert
Medical treatment administered (please specify where/by whom etc):
Please Insert
Assistance sought: (please specify type) Ambulance Police Counsellor
Equipment shut down (please specify what/when etc):
Please Insert
Centre closed (please specify exact time): Please Insert
Repair person contacted (please specify whom):
5. Other information
Sparkling Stars Incident Report Form V1.0 – Produced 30 August 2024
Page 2 of 3
© Commonwealth of Australia 2012, Licensed under Creative Commons Attribution-ShareAlike 3.0 Australia License

Who witnessed the incident? (please use full name, details of staff’s job title where
applicable, and telephone number/s):
NOTE: Be specific. Describe in detail what actually happened, stating the facts in a
clear and precise manner. Include exact location of incident, factors involved and any
other details that may be beneficial. A drawing of the centre layout, identifying where
the incident occurred, would be useful.
Please Insert
6. Other information
This report was compiled by (full name, title and contact telephone):
Please Insert
On (date/time):
Please Insert
This report is a true and accurate summary of the incident that occurred (please sign):
Please Insert
Sparkling Stars Incident Report Form V1.0 – Produced 30 August 2024
Page 3 of 3
© Commonwealth of Australia 2012, Licensed under Creative Commons Attribution-ShareAlike 3.0 Australia License