Gull -TNZ Initial Incident Report - Rev 3.1

Gull - TNZ Initial Incident Report

• Incident reported by

Incident classification

• Injury

• Select Fatality Lost Time Injury Hospitalisation Serious Harm (fracture, loss of conciousness, amputation ... ) Medical Treatment Injury (treatment that can only be applied by a medical practitioner) First Aid

  • Fatality
  • Lost Time Injury
  • Hospitalisation
  • Serious Harm (fracture, loss of conciousness, amputation ... )
  • Medical Treatment Injury (treatment that can only be applied by a medical practitioner)
  • First Aid

• Environmental

• Select Spill to land Spill to water Unauthorised release to air

  • Spill to land
  • Spill to water
  • Unauthorised release to air

• Quality

• Asset damage

• Near miss

• Identified hazard

Incident details

• Address of incident
  Address

• Date and time of incident

  Date

• Summary of event

• Was a vehicle or item of equipment involved in the incident?

• Provide vehicle or equipment details

• Provide details of driver or operator

• Were there any witnesses?

• Provide name(s) and contact details of witnesses

• Was any product spilled to ground?

• Enter type and volume of product spilled.

• Was the facility closed as a result of the incident?

• Hours facility was closed.

• Were emergency services or a regulatory authority involved in the incident response?

• Fire brigade

• Ambulance

• Police

• WorkSafe

• Council

• Other (detail)

• Was weather a contributing factor?

• Enter weather conditions

• Actual risk of incident

  Select Extreme Medium - High Low

  • Extreme
  • Medium - High
  • Low

• Potential risk of incident

  Select Extreme Medium - High Low

  • Extreme
  • Medium - High
  • Low

• Only if safe, provide a photo of the incident scene

  Media

Corrective action

• Provide brief summary of any immediate corrective action(s) taken

• When the report is complete, forward a copy to your manager and to MichaelJ@gull.co.nz