Title Page

  • Incident Report No:

  • Audit Title: Incident/Accident Report

  • Company:

  • Conducted on

  • Reported by:

Incident/Accident Report

  • 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.


  • Incident Report No:

  • Date Accident/Incident reported

  • Name of Person completing Report

  • Position/Role of person reporting


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

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

  • Day of accident or incident:

  • Injured/Involved Person Name:

  • Role/Position:

  • Contact Phone Number

  • Date of Birth

  • Length of employment/contract of worker:

  • Shift Worked when accident or incident happened:

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

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

  • Were other people involved?

  • 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.

  • 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


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

  • Action
  • What was the action conducted?

  • Who completed this action?

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

  • Action
  • What is the action to be conducted.

  • Who is person responsible for this action.

  • Due Date for completion.

  • Is this a WORKSAFE NZ NOTIFIABLE injury or incident?

  • What type of Notifiable Event is it?

  • Name of person who notified Work Safe NZ

  • Method of Notification

  • Date of Notification


  • Name and Signature of Person Completing this Report Form.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.