Incident Report Form

All incidents must be recorded using this form as soon as possible after the immediate response to an incident.

If you already made a report to an external authority such as the DCJ Child Protection Helpline or the Police, you still need to complete this form.

Once completed, this form will be sent to Playgroup NSW management for review and action.

What is your role with Playgroup NSW? *

Staff memberVolunteer

What category of incident has occurred? Please refer to the definitions and examples below. *

Level 1 (minor)Level 2 (significant)Level 3 (serious)

INCIDENT DEFINITIONS

Level	Impact	Description	Report due
1	Minor	A simple issue that can be informally managed and quickly resolved at a local level.	Within 2 days
2	Significant	Incident is of a more complex nature and may require a formal assessment or investigation to resolve the matter.	Within 1 day
3	Serious	Incident with immediate and harmful consequences, requires an emergency response or urgent action.	Same day

EXAMPLES OF INCIDENT TYPES AND LEVELS

Incident Type	Level 1 (Minor)	Level 2 (Significant)	Level 3 (Serious)
Staff injury/illness (work related) Volunteer, child or family member injury/illness arising from PGNSW services	Minor cut, burn or sprain, first aid applied	Bone fracture, long term infection, medical treatment and extended time off needed (more than 1 week)	Life threatening medical event or death. Emergency Services contacted and person hospitalised.
Child or family safety risk * Except for Level 3, first refer to the Child Safety Policy to understand how to use the Mandatory Reporters Guide.	Concerns raised, Risk of Significant Harm (ROSH) threshold not met.	Concerns raised, ROSH threshold met and DCJ Child Protection report made (record reference number).	Imminent threat to a person's safety and Police report made (record reference number).
Staff, volunteer, child or family data breach * A data breach occurs when there is unauthorised access to, unauthorised disclosure of, or loss of personal information that PGNSW holds.	One person's information is accidentally sent to the wrong email recipient.	A phishing email successfully compromises a PGNSW account and may expose company information and/or personal information of multiple people.	PGNSW databases are breached and contain the personal information of multiple people, including identifying, medical and financial information.
Staff own motor vehicle accident (work related)	Vehicle has minor damage but is still driveable.	Vehicle requires towing for repairs or is irreparable, and staff member needs time off work.	N/A
PGNSW vehicle accident damage, loss or theft	Minor damage, vehicle remains driveable.	Vehicle requires towing.	Vehicle is irreparable, lost or stolen.
PGNSW IT equipment damage, loss or theft	Phone or laptop damaged (e.g. cracked screen, dropped device).	Loss or theft of phone or laptop.	Fire, flood or other event causes complete loss of PGNSW website or database information.
PGNSW office door key fob damage, loss or theft	Key fob damaged.	Key fob lost or stolen.	N/A
PGNSW workplace hazard	Hazards such as torn carpet, slippery floors or faulty play equipment that create a safety risk.	Property issue requiring significant cost or time to rectify (e.g. electrical fire, confined area unusable).	Major property damage or dangerous hazard rendering the site unsafe (e.g. flooding, fire, chemical spill, gas leak or roof collapse).

EXAMPLES OF INCIDENT TYPES

Incident Type	Level 1 (Minor)	Level 2 (Significant)	Level 3 (Serious)
Volunteer, child or family member injury/illness arising from PGNSW services	Minor cut, burn or sprain, first aid applied.	Bone fracture, long term infection, medical treatment and extended time off needed (more than 1 week).	Life threatening medical event or death. Emergency Services contacted and person hospitalised.
Child or family safety risk * You can read more about Risk of Significant Harm in our Child Safety Policy.	Concerns that there is a Risk of Significant Harm (ROSH), but you are unsure whether it should be reported to an authority.	Concerns that there is a Risk of Significant Harm (ROSH) and you phoned the Child Protection Helpline on 13 21 11.	Imminent threat to a person's safety and you have reported it to Police.
Staff, volunteer, child or family data breach * A data breach occurs when there is unauthorised access to, unauthorised disclosure of, or loss of personal information that PGNSW holds. This includes information about an individual whose identity is apparent or can reasonably be identified.	One person's information is accidentally sent to the wrong email recipient (including a personal email account).	A phishing email successfully compromises a Playgroup account and scammers may gain access to company or personal information of multiple people.	Playgroup databases have been breached and contain personal information of multiple people, including identifying, medical and financial information.
Community playgroup equipment or location hazard	Hazards such as torn carpet, slippery floors or faulty/broken play equipment creating a slip, trip or fall risk.	Property issue requiring significant cost or time to rectify (for example, electrical fire or part of the site becoming unusable).	Major property damage or dangerous hazard that renders the site unsafe (for example, flooding, fire damage, chemical spill, gas leak or roof collapse).

LEVEL 1 INCIDENT

This form will be directed to your manager or Program Lead for their review and action.

LEVEL 2 INCIDENT

This form will be directed to your manager or Program Lead, as the relevant Executive Leader, for their review and action.

LEVEL 3 INCIDENT

This form will be directed to your manager/Program Lead, the relevant Executive Leader, and the CEO for their review and action.

LEVEL 1 INCIDENT

This form will be directed to the Program Lead Community for their review and action.

LEVEL 2 INCIDENT

This form will be directed to the Program Lead Community and Executive Lead Services for their review and action.

LEVEL 3 INCIDENT

This form will be directed to the Program Lead Community, Executive Lead Services, and CEO for their review and action.

STAFF INFORMATION

Full Name *

Email *

Position *

Date of submission *

INCIDENT DETAILS

Where did the incident occur? *

PlaygroupEventHead OfficeOther

Incident relates to *

Address or other details of where the incident occurred *

When did the incident occur? (date) *

Time of day *

Briefly describe what happened *Include the nature of the incident (e.g. what body part is injured, illness symptoms) and cause of the incident (e.g. slippery floor, severe weather, family situation)

Were any individuals affected by this incident? *

YesNo

Name of person affected by the incident

Full name of parent/carer (if affected person is a child)

Affected person contact number (if a child, please use parent/carer details)

Equipment damage: Please describe damage

Was there a witness or family member present during the incident? *

YesNo

Witness full name

Witness relationship to the person

Witness phone

Witness email

ACTIONS TAKEN

Name of Manager/Program lead notified

Manager email address

Date notified

DCJ report reference

Police report reference

Other action taken

Attach files/images where relevant

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YOUR DETAILS

Full name (person completing the form) *

Phone number *

Date of submission *

ABOUT THE INCIDENT

Playgroup Name (please include suburb) *

Incident relates to

Where did the incident occur? (Playgroup or other address) *

When did the incident occur? (date) *

When did the incident occur? (time) *

Incident type (select main one) *

Volunteer injury or illness arising from Playgroup NSW servicesChild/family injury or illness arising from Playgroup NSW servicesChild/family safety riskChild/family otherVolunteer safety riskVolunteer, child or family data breachPlaygroup equipment or location hazard

If child/family other, please specify

Briefly describe what happened *Include the nature of the incident (e.g. what body part is injured, illness symptoms) and cause of the incident (e.g. slippery floor, severe weather, family situation)

Were any individuals affected by this incident? *

YesNo

Name of person affected by the incident

Full name of parent/carer (if affected person is a child)

Contact number – affected person (if a child, please use parent/carer details)

Was there a witness or family member present during the incident? *

YesNo

Witness name

Witness relationship to the person

Witness phone number

Witness email

ACTION TAKEN

Name of Program Lead notified

Email (if known)

Date notified

Child protection report reference

Police report reference

Other action taken

Attach files/images where relevant

Browse