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Audit

Name of organisation

Branch/department

Particulars of Accident

Date of accident
Time
Location
Date Reported

The Injured Person

Name

Address
Date of birth

Phone number

Length of employment - at plant

On job

Type of injury

Specify injured part of body

Comments

Damaged Property

Property or material damaged:

Attach media (if applicable)

Nature of damage:

Attach media (if applicable)

Object/substance causing damage:

Attach media (if applicable)

The Accident

Describe what happened

Drawing of the accident scene (For vehicle accidents / where appropriate)

What caused the accident?

How serious could it have been?

How often is this likely to happen again?

What action has or will be taken to stop another accident like this happening?

Action

Description

Completed?

By whom

When

Treatment and Investigation of Accident

Type of treatment given

Name of person giving first aid

Doctor/Hospital

Accident investigated by

Signature
Date

WorkSafe advised?

Select date

Accident Investigation Form - Worksafe NZ Checklist

Created by: SafetyCulture Staff | Industry: Construction | Downloads: 13,675

Created by WorkSafe New Zealand, this accident investigation form can be used to record details of an incident as part of an investigation.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

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Audit

Name of organisation

Branch/department

Particulars of Accident

Date of accident
Time
Location
Date Reported

The Injured Person

Name

Address
Date of birth

Phone number

Length of employment - at plant

On job

Type of injury

Specify injured part of body

Comments

Damaged Property

Property or material damaged:

Attach media (if applicable)

Nature of damage:

Attach media (if applicable)

Object/substance causing damage:

Attach media (if applicable)

The Accident

Describe what happened

Drawing of the accident scene (For vehicle accidents / where appropriate)

What caused the accident?

How serious could it have been?

How often is this likely to happen again?

What action has or will be taken to stop another accident like this happening?

Action

Description

Completed?

By whom

When

Treatment and Investigation of Accident

Type of treatment given

Name of person giving first aid

Doctor/Hospital

Accident investigated by

Signature
Date

WorkSafe advised?

Select date