Accident/Incident Report

• Incident Report No:

• Audit Title: Incident/Accident Report

• Company:

• Conducted on

  Date

• Reported by:

• Complete this Accident/Incident Report Form as accurately and with as much detail as possible. Submit this report within 12-24 hours or as soon as practicable to the Crew Foreman/Supervisor, Health & Safety representative or Director/Principal for an Investigation to be scheduled as soon as possible.

GENERAL INFORMATION

• Incident Report No:

• Date Accident/Incident reported

  Date

• Name of Person completing Report

• Position/Role of person reporting

ACCIDENT/INCIDENT INFORMATION

• Accident or Incident Injury/Damage Type (select all applicable)

  Select Near Miss First Aid Medical-Doctor Only Medical-Hospitalised Motor Vehicle-No Injury Motor Vehicle-Injury Property Damage-No Injury Property Damage-Injury Process Breach-Internal Process Breach-External Serious Harm - Notifiable

  • Near Miss
  • First Aid
  • Medical-Doctor Only
  • Medical-Hospitalised
  • Motor Vehicle-No Injury
  • Motor Vehicle-Injury
  • Property Damage-No Injury
  • Property Damage-Injury
  • Process Breach-Internal
  • Process Breach-External
  • Serious Harm - Notifiable

• Date and Time of Incident (be as accurate as possible)

  Date

• Day of accident or incident:

  Select Monday Tuesday Wednesday Thursday Friday Saturday Sunday

  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday
  • Sunday

• Injured/Involved Person Name:

• Role/Position:

• Contact Phone Number

• Date of Birth

  Date

• Length of employment/contract of worker:

• Shift Worked when accident or incident happened:

  Early Morning

  Day

  Afternoon-After Day Shift

  Night

• Incident Location (Forest, Road/s, Crew, Setting#)

• Weather/Environmental Condition/s (select all that apply)

  Select Fine Warm Hot Very Hot Dusty Cold Wet Cloudy Showers Rain Windy Stormy (lightening) Snow/Sleet

  • Fine
  • Warm
  • Hot
  • Very Hot
  • Dusty
  • Cold
  • Wet
  • Cloudy
  • Showers
  • Rain
  • Windy
  • Stormy (lightening)
  • Snow/Sleet

• Were other people involved?

  Yes

  No
Person/Phone

• Person's First name and Surname

• Contact Phone Number

• Position/Role and Company (if an external worker)

• If injured, indicate on drawing where the injury or injuries were sustained.

  Drawing

• If injured and First Aid was provided - what treatment was given:

• Name of First Aider who provided the treatment:

• Accident or Incident Details: Provide step by step information of - what you were doing when or just before the accident or incident happened - what actually happened - what you think might have caused the accident or incident - what happened immediately after the accident or incident up to when it was first report

ACTIONS

• Were there any IMMEDIATE action/s conducted or completed?

  Yes

  No
Action

• What was the action conducted?

• Who completed this action?

• Any Corrective or Preventative Action/s to be Implemented?

  Yes

  No
Action

• What is the action to be conducted.

• Who is person responsible for this action.

• Due Date for completion.

  Date

• Is this a WORKSAFE NZ NOTIFIABLE injury or incident?

  Yes

  No

• What type of Notifiable Event is it?

  Select Notifiable Injury Notifiable Illness Notifiable Property Damage Notifiable Motor Vehicle

  • Notifiable Injury
  • Notifiable Illness
  • Notifiable Property Damage
  • Notifiable Motor Vehicle

• Name of person who notified Work Safe NZ

• Method of Notification

  Telephone

  Email

  Submitted Online

• Date of Notification

  Date

SIGN OFF

• Name and Signature of Person Completing this Report Form.

  Sign