School Allergy Serious Incident and Near-Miss Record

Select all that apply.

Enter the date on which the incident or near miss occurred.

Use 24-hour time if known; otherwise provide an approximate time.

Include the relevant room, area, trip location or activity.

Enter the name and role of the person completing the record.

Enter the date on which this record was completed.

Do not include more personal information than is necessary for this record.

Use the school's approved identifier or record the person's name only where necessary and permitted by school procedures.

Record the known or suspected allergen. If it is not known, state that.

Describe observed symptoms, signs of reaction or the potential exposure in factual terms. For a near miss with no symptoms, state that no symptoms were observed.

Set out the sequence of events, including what was noticed, by whom and when.

Include relevant information about food, medication, contact, activities, supervision, environmental conditions or other circumstances.

Record factors that may have contributed. Avoid assigning blame; distinguish confirmed facts from matters still being investigated.

Explain the selected factors and identify any information that remains to be checked.

Record the actions taken, by whom and in what order. Follow emergency procedures separately where required.

Select the applicable response.

Record the applicable response and provide details below where medication was administered.

If medication was administered, record the medication, dose if known, time and person who administered it. If not administered, state why this field is not applicable.

Include actions to protect the affected person and others, preserve relevant information and address any immediate risk.

Record notifications made in accordance with applicable school procedures, including the date and time where relevant.

Record what the school has learned from the serious incident or near miss, including what worked and what may need to change.

List each action, the person responsible, the target date and the current status.

Enter the date for the review or the date on which the review was completed.

Summarise the review outcome and identify any actions or information still outstanding.

Confirm that the information recorded is accurate to the best of your knowledge and that outstanding actions have been identified.

• Tick when complete