Title Page
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Site Address
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Conducted on
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Prepared by
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Location
Section 1 (to be completed by worker)
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Date and time of event
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Location
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Job Number
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Type of event
- Injury
- Illness
- Near Hit
- Damage/Loss
- Notifiable Event
- Environmental
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Reported by
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Phone
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Person involved
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Name
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DOB:
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Address
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Phone
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Vehicle Rego (if applicable)
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Vehicle Make/Model
Witness
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Name
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Phone
Describe the Event
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Desciption of the event
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Describe any illness or injury: what body part is affected and how?
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Describe any property/environmental damage: What damage was caused and how
- 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)
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Analysis: What do you think caused or contributed to the event
- 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)
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Why did the event occur?
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Associated Risks:
Preventative/corrective actions:
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What action has been/can be taken to prevent a reoccurance
Treatment
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Doctor
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Type of treatment provided
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Hospital
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Type of treatment provided
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ACC45 received
Notification and investigation (WORKSAFE PHONE 0800 030 040 as soon as practical and completed online form
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Worksafe NZ advised
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Date notified
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Investigation conducted /reviewed by:
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Date investigated
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Associated Risk/s reviewed by:
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Date reviewed
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Authorised signature
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Date
