ASSESSMENT 1 – PART A STUDENT INFORMATION

This information is to be handed to each student to outline the assessment requirements

Using the following Accident Report Form you are to fill in the details from the scenario below.

INJURY SCENARIO:

On 12 January 2017, you witnessed Joanne Smyth slip down the stairs at work (VIT – Queens St,
Melbourne) and injured her left ankle. The first aid officer (Ian Jones) applied ice, elevation and a pressure
bandage to the injured ankle. Joanne was then taken to the staff-room to rest her ankle, as she did not want to
go home. You heard that Joanne was distracted as she was talking on her telephone whilst approaching the
stairs, but you did not see this first hand. You also suggested she go to the doctors within the next 1-3 days
for further evaluation of the injury

Please Note: You may add any missing facts or information for the purpose of this task

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 INCIDENT REPORT FORM (Page 1 of 2)
PERSONAL DETAILS OF THE INJURED PERSON

Title: Dr Mr Ms Mrs Miss

Surname: SMTYH Given Names: JOANNE
Gender: Male / Female Date of Birth: 17 / MARCH / 1991 ( Date / Month / Year)
 Employee Employee No: VIT-123-456 FT / PT / Casual
 Independent Person
Home Address:10 MARJORY STREET YARRAVILLE
Telephone: Home: N/A Work: N/A Mobile: 0404538191
Occupation: ADMIN STAFF Email: JOANNESMYT@VIT.COM

PERSONAL DETAILS OF THE FIRST AIDER

Title: Dr Mr Ms Mrs Miss
Surname: JONES Given Names: IAN
Gender: Male / Female Date of Birth: 31/AUGUST/1985 (Date / Month / Year)
 Employee Employee No: VIT-123-458 FT / PT / Casual
 Independent Person
Home Address: 256 FRANCIS STREET YARRAVILE
Telephone: Home: 123-456-789 Work: N/A Mobile: 0404836925
Occupation: IT STAFF/ FIRST AID OFFICER Email: IANJONES@VIT.COM

DETAILS OF THE ACCIDENT

Day of Accident: TUESDAY Date of Accident: 12/JANUARY/2017 Time of Accident:11:30 am /pm
Location of Accident: VIT-QUEEN STREET , MELBOURNE
What was the person doing leading up or at the time of the accident (e.g. sweeping leaves):
JOANNE WAS DISTRACTED AS SHE WAS TALKING ON HER PHONE WHILST APPROACHING
THE STAIRS
What actually happened: (e.g. slipped on floor, struck by car):
SLIPPED DOWN THE STAIRS
What object/machine was being used at the time of the accident (e.g. guillotine):
ICE, BANDAGE AND OBJECT FOR ELEVATION
What safety equipment was being used at the time (e.g. gloves, goggles, earmuffs): _
N/A
Was the hazard that caused the accident / injury previously reported? Yes / No / N/A Has the
hazard been resolved: Yes / No / N/A

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 INJURY / CONDITION / DISEASE DETAILS

Description of the injury / condition / disease:

JOANNE SLIPPED DOWN TO THE STAIRS AND INJURED HER LEFT ANKLE
Bodily location of the injury / condition / disease
Arm – Lower L/R Arm – Upper L/R Hand L/R Finger/s
Leg – Lower L/R Leg – Upper L/R Foot L/R Toe/s
Skull Face Eye L/R Nose
Mouth Ear L/R Neck Shoulder/s L/R
Chest Abdomen Hip L/R Internal Organs
Back - Upper Back - Lower Buttocks Other
LEFT ANKLE

INJURY / CONDITION / DISEASE DETAILS

Description of the injury / condition / disease:
JOANNE SLIPPED DOWN TO THE STAIRS AND INJURED HER LEFT ANKLE

WITNESSES/ES
Name: NORIKO MAIKO SARMIENTO Contact No: +61404538191
Name: Name:
Contact No: _
Name:
Contact No: _
Contact No: _

ACTION TAKEN
Detail action taken as a result of this accident: THE FIRST AID OFFICER APPLIED ICE , ELEVATION AND
A PRESSURE BANDAGE TO THE INJURED ANKLE. JOANNE WAS TAKEN TO THE STAFF- ROOM
TO REST HER ANKLE

TO BE COMPLETED BY FIRST AIDER

Name: IAN JONES Contact No: 0404836925
Signature: _ Date: 12/ JANUARY / 2017

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