Title Page
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Reported on
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Reported by
Incident Details
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Employee/s involved (add employee names into response set)
- None
- Employee 1
- Employee 2
- Employee 3
- Employee 4
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Contractor/s involved (add contractor names into response set)
- None
- Contractor 1
- Contractor 2
- Contractor 3
- Contractor 4
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Description of incident
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Incident Type (update options to suit business and match Master Files)
- Accident
- Equipment damage
- Illness
- Near miss
- Property damage
- Serious harm
- Vehicle damage
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Who reported the incident? (add employee names into response set)
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Location Type (update options to suit business and match Master Files)
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Location (update options to suit business and match Master Files)
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When did the incident happen?
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When was the incident reported? If now, click "Now"
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What shift were the affected employees working? (update options to suit business and match Master Files)
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What time did the affected employees start work?
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How long have they been employed with this business? (update options to suit business and match Master Files)
- Less than 6 months
- 6 months - 1 year
- 1 - 2 years
- 2 - 3 years
- 3 - 4 years
- 4 - 5 years
- 5 years and over
Incident Management
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The administrator will note down the incident manager, the management and corrective actions, etc, when entering information into the Hasmate program.
Accident/Harm/Illness
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Please click the link below for definitions of terminology used
https://www.hasmate.co.nz/helpdesk-articles/incidents/incident-definitions/ -
Agency (cause) - something that was involved or happened to produce a particular result.
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Mechanism (effect) - the process, system or thing that caused the incident to happen
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Body part/s involved
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Injury Category (update options to suit business and match Master Files)
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Injury Nature (update options to suit business and match Master Files)
- Amputation of any body part
- Bruising
- Crushing
- Cut to head or body parts
- Death
- Eye injury
- Injury or illness that requires (or would usually require) immediate hospital admittance
- Injury or illness that requires (or would usually require) medical treatment within 48 hours of exposure to a substance
- Loss of bodily functions
- Minor abrasion
- Other injury or illness declared notifiable by regulations
- Separation of skin from underlying tissue (scalping or degloving)
- Serious burn
- Serious eye injury
- Serious head injury
- Serious infection (including occupational zoonosis)
- Serious lacerations – an incident that requires stitches (e.g. cut tendons, ligament, nerves)
- Small cut/s
- Spinal injury
- Strains and sprains
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Injury Treatment (update options to suit business and match Master Files)
Property Damage
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Was any company property damaged in this incident (vehicles, equipment, buildings, etc)?
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Please note down what property was damaged. If vehicles, please note down registration number/s. If equipment, please describe.
Other Property Damage
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Was any other property damaged in this incident (vehicles, equipment, buildings, etc owned by other people)?
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Please note down what property was damaged. If vehicles, please note down registration number/s. If equipment, please describe.
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Was there any environmental impact?
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Please note down what the impact was.
Images
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Upload images related to this incident (property damage, etc)
