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:
Name of Person completing Report
Position/Role of person reporting
- 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
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
Injured/Involved Person Name:
Role/Position:
Contact Phone Number
Length of employment/contract of worker:
Shift Worked when accident or incident happened:
Incident Location (Forest, Road/s, Crew, Setting#)
- Fine
- Warm
- Hot
- Very Hot
- Dusty
- Cold
- Wet
- Cloudy
- Showers
- Rain
- Windy
- Stormy (lightening)
- Snow/Sleet
Were other people involved?
Person's First name and Surname
Contact Phone Number
Position/Role and Company (if an external worker)
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?
What was the action conducted?
Who completed this action?
Any Corrective or Preventative Action/s to be Implemented?
What is the action to be conducted.
Who is person responsible for this action.
Is this a WORKSAFE NZ NOTIFIABLE injury or incident?
