Incident Report Form Incident Reporter’s Details (Staff Member only) Reporter’s Date incident reported /______/______ Name Phone Position ECU Sport & School / Service Centre Email Fitness Witness name and contact number if different from above Relationship of witness to person invovled Incident Details Date of incident _____ /______/______ Campus Joondalup / Mt Lawley Where incident happened: _______________________________________________________ _______________________________________________________ _______________________________________________________ Incident Description _______________________________________________________ Please tick if applicable Did the incident involve Electricity If so, please report to Facilities and Services Desk on 5554 Fire or Property Damage If so, please report to ECU Insurance Involved Person’s Details Person who was involved in or injured in the incident Position / Involved Person’s Name Occupation Phone Email Address Staff number Staff ECU Student number Student ECU Contractor Is the involved person Contractor Company name Contact person Visitor / child in Crèche name / guardian Involved Person’s Supervisor Supervisor’s Email Name (if an ECU member) Supervisor’s Phone Number Yes Was an injury sustained? If yes, please complete injury details section. No
Incident Report Form Incident Reporter’s Details (Staff Member only) Date incident reported /______/______ Reporter’s Name Phone Position School / Service Centre ECU Sport & Fitness Email Witness name and contact number if different from above Relationship of witness to person invovled Incident Details Date of incident _____ /______/______ Campus Joondalup / Mt Lawley Where incident happened: Incident Description _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ Did the incident involve Please tick if applicable Electricity If so, please report to Facilities and Services Desk on 5554 Fire or Property Damage If so, please report to ECU Insurance Involved Person’s Details Person who was involved in or injured in the incident Involved Person’s Name Position / Occupation Phone Email Address Is the involved person ECU Staff Staff number ECU Student Student number Contractor Contractor Company name Visitor / child in Crèche Contact person name / guardian Involved Person’s Supervisor Name (if an ECU member) Supervisor’s Email Supervisor’s Phone Number Was an injury sustained? Yes No If yes, please complete injury details section.
Incident-report-Hardcopy-of-online-form-issue-2-July-2015.docx