JC Civil Event Report

• Site Address

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Date and time of event

  Date

• Location

• Job Number

• Type of event

  Select Injury Illness Near Hit Damage/Loss Notifiable Event Environmental

  • Injury
  • Illness
  • Near Hit
  • Damage/Loss
  • Notifiable Event
  • Environmental

• Reported by

• Phone

• Person involved

  Employee

  Contractor

  Member of Public

• Name

• DOB:

• Address

• Phone

• Vehicle Rego (if applicable)

• Vehicle Make/Model

Witness

• Name

• Phone

Describe the Event

• Desciption of the event

• Describe any illness or injury: what body part is affected and how?

• Describe any property/environmental damage: What damage was caused and how

  Select Materials (hazardous substances, timber, nails etc) Equipment (tools, plant, vehicle faulty/not fit for purpose) Environment (noise, temperature, heights, terrain) People (no instructions, not authorised, inexperienced)

  • Materials (hazardous substances, timber, nails etc)
  • Equipment (tools, plant, vehicle faulty/not fit for purpose)
  • Environment (noise, temperature, heights, terrain)
  • People (no instructions, not authorised, inexperienced)

Section Two (to be completed by investigator)

• Analysis: What do you think caused or contributed to the event

  Select Materials (hazardous substances, timber, nails etc) Equipment (tools, plant, vehicle faulty/not fit for purpose) Environment (noise, temperature, heights, terrain) People (no instructions, not authorised, inexperienced)

  • Materials (hazardous substances, timber, nails etc)
  • Equipment (tools, plant, vehicle faulty/not fit for purpose)
  • Environment (noise, temperature, heights, terrain)
  • People (no instructions, not authorised, inexperienced)

• Why did the event occur?

• Associated Risks:

Preventative/corrective actions:

• What action has been/can be taken to prevent a reoccurance

Treatment

• Doctor

  Yes

  No

• Type of treatment provided

• Hospital

  Yes

  No

• Type of treatment provided

• ACC45 received

  Yes

  No

Notification and investigation (WORKSAFE PHONE 0800 030 040 as soon as practical and completed online form

• Worksafe NZ advised

  Yes

  No

• Date notified

  Date

• Investigation conducted /reviewed by:

• Date investigated

  Date

• Associated Risk/s reviewed by:

• Date reviewed

  Date

• Authorised signature

  Sign

• Date

  Date