DGC Accident Investigation

Accident Investigation - to be completed by manager together with those involved

• Select DGC Branch

  Auckland

  Waikato

  Central Plateau

  Wellington

  NZ Office

Particulars of Accident

• Date & Time accident occurred

  Date
• Location of accident
  Address

• Date Reported

  Date

The Injured Person

• Name

• Address
  Address

• Age

• Phone Number

INDICATION OF INJURIES

• Were there any injuries?

  YES

  NO

• Type of Injury

  Select Strain/sprain Fracture Laceration/cut Bruising Scratch/abrasion Amputation Burn scald Dislocation Internal Foreign body Chemical reaction Other (specify)

  • Strain/sprain
  • Fracture
  • Laceration/cut
  • Bruising
  • Scratch/abrasion
  • Amputation
  • Burn scald
  • Dislocation
  • Internal
  • Foreign body
  • Chemical reaction
  • Other (specify)

• Injured part of body

• DETAILS OF INJURY?

• PHOTOGRAPHS OF INJURY

  Media

Damage to Property

• Was there any damage to property?

  YES

  NO

• RECORD DETAILS AND EXTENT OF DAMAGE

• PHOTOGRAPHS OF DAMAGE

  Media

Witnesses

• Were there any witnesses?

  YES

  NO

• RECORD DETAILS OF WITNESSES

The Accident

• Description (describe what happened)

• Analysis (what were the root causes?)

• How bad could it have been?

  Very Serious

  Serious

  Minor

• How likely is it to occur again?

  Very Likely

  Occasional

  Very Unlikely

Treatment of Accident

• Type of Treatment Given

• Name of Person Giving Treatment

• Doctor/ Hospital

WorkSafe

• WorkSafe Notified?

  YES

  NO

• Date WorkSafe notified

  Date

Recommendations (include any corrective, preventive actions)

• Recommendations/ Actions?

Photographs

• Photographs

  Media

Report completed by:

• Investigation completed by::

• DATE OF INVESTIGATION REPORT

  Date