Placement Incident/Accident/Injury Report
OPTION 2
SECTION 1 STUDENT DETAILS
Student ID Contact Number
Surname Given Names
Home Address
Town State Post Code
SECTION 2 COURSE DETAILS
Course Name Discipline
Current Year Level Year Level Elective
SECTION 4 DESCRIPTION OF INCIDENT
Please provide all relevant information as soon as possible after the incident to the best of your ability as the
incident must be recorded on the JCU Riskware Management database.
Division of Tropical Health & Medicine: version 2 November 2015
SECTION 3 DETAILS OF OVERSEAS PLACEMENT
Host Organisation Name
Host Organisation Address
Host Organisation Contact
Person
Host Organisation Email
Address
Placement Supervisor’s
Name
Placement Start Date Placement End Date
INFORMATION REQUEST
Time and date of the incident
Were you working in a placement venue at the time of the incident? YES NO
Where did it happen?
Were you travelling to or from placement at time of
incident?
Yes
No
Were you using your own vehicle, hire vehicle or
public transport?
Any injury to yourself? e.g. stress, laceration on
left arm, bruised right to etc.
Did you require an ambulance? YES NO
Damage to vehicle? eg. Significant: unable to
drive vehicle, or vehicle still serviceable etc..
Any witnesses to the incident? YES NO
Witness name and contact details.
What immediate a
ction was taken after the incident?
When was the incident reported to the placement
preceptor?
Time Day Date
When was the incident reported to JCU placement
office?
Time Day Date
Who was the incident reported to at JCU
placement office?
Did you contact the police regarding the incident? YES NO
Time Date
Did you contact your Insurance organization
regarding the incident?
YES NO
Time Date
Possible rate of consequence of the incident
(Placement office use only)
Insignificant Low Medium High Extreme
Any incident which is believed may possibly results in a claim against the University’s
insurance policy should be notified immediately to the Insurance Officer, Resources Office.
Email: insurance@jcu.edu.au
Student Signature Date
Supervisor Signature Date
Division of Tropical Health & Medicine: version 2 November 2015
No
Sun
Sun
SUBMIT FORM
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