Notice Or Record of Accident/Serious Harm (NZ)

• Audit Title

• Company

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel On Site

1) Particulars of employer, self employed person or principal. (Business name, postal address and telephone number)

2) The person reporting is

• Yes

  No

  N/A

• An employer

  Yes

  No

  N/A

• A principal

  Yes

  No

  N/A

• A self employed person

  Yes

  No

  N/A

3) Location of work place (Track, Building etc)

• Add location
  Address

4) Personal data of injured person

• Name

• Residential address
  Address

• Date of birth

  Date

• Sex

  Select Male Female

  • Male
  • Female

5) Occupation or Job title of injured person ( employees and self employed persons only)

6) The injured person is

• Select An employee Self A contractor (self employed person) other

  • An employee
  • Self
  • A contractor (self employed person)
  • other

7) Period of employment of injured person

• Select 1st week 6 months - 1 year Non employee 1st Month 1 - 6 Months 1 - 5 years Over 5 years

  • 1st week
  • 6 months - 1 year
  • Non employee
  • 1st Month
  • 1 - 6 Months
  • 1 - 5 years
  • Over 5 years

8) Treatment of injury

• Select None First Aid only Doctor but no hospitalisation Hospitalisation

  • None
  • First Aid only
  • Doctor but no hospitalisation
  • Hospitalisation

9) Time and date of accident / serious harm

• Select date

  Date

• Shift

  Select Day Afternoon Night

  • Day
  • Afternoon
  • Night

10) Mechanism of accident/ serious harm

• Type of mechanism

  Select Fall/ trip or fall Sound or pressure Body stressing Biological factors Mental stress Hitting objects with part of the body Being hit by moving objects Heat, radiation or energy Chemicals or other substances

  • Fall/ trip or fall
  • Sound or pressure
  • Body stressing
  • Biological factors
  • Mental stress
  • Hitting objects with part of the body
  • Being hit by moving objects
  • Heat, radiation or energy
  • Chemicals or other substances

11) Agency of accident or serious harm

• Enter type of agency

  Select Machinery or fixed plant Mobile plant or transport Powered equipment, tool or appliance Non powered hand tool, appliance or equipment Chemical product or chemical Material or substance Environment exposure (dust, gas) Animal, human or biological agency (other than bacteria or virus) Bacteria or virus

  • Machinery or fixed plant
  • Mobile plant or transport
  • Powered equipment, tool or appliance
  • Non powered hand tool, appliance or equipment
  • Chemical product or chemical
  • Material or substance
  • Environment exposure (dust, gas)
  • Animal, human or biological agency (other than bacteria or virus)
  • Bacteria or virus

12) Bodypart

• Enter bodypart

  Select Head Upper limb Neck Lower limb Systemic internal organs Trunk Multiple locations

  • Head
  • Upper limb
  • Neck
  • Lower limb
  • Systemic internal organs
  • Trunk
  • Multiple locations

13) Nature of injury or disase

• Enter type

  Select Fracture of spine Other fracture Dislocation Sprain or strain Head injury Internal injury of trunk Amputation, including eye Open wound Superficial injury Bruising or crushing Foreign body Burns Nerves or spinal cord Puncture wounds Poisoning or toxic effects Multiple injuries Damage to artificial aid Disease, skin Disease, nervous system Disease, musculoskeletal system Disease, digestive system Disease, infectious or parasitic Disease, respiratory system Disease, circulatory system Tumor (malignant or benign) Mental disorder

  • Fracture of spine
  • Other fracture
  • Dislocation
  • Sprain or strain
  • Head injury
  • Internal injury of trunk
  • Amputation, including eye
  • Open wound
  • Superficial injury
  • Bruising or crushing
  • Foreign body
  • Burns
  • Nerves or spinal cord
  • Puncture wounds
  • Poisoning or toxic effects
  • Multiple injuries
  • Damage to artificial aid
  • Disease, skin
  • Disease, nervous system
  • Disease, musculoskeletal system
  • Disease, digestive system
  • Disease, infectious or parasitic
  • Disease, respiratory system
  • Disease, circulatory system
  • Tumor (malignant or benign)
  • Mental disorder

14) Where and how did the accident / serious harm happen?

14 a) photos if applicable

• Add media

  Media

15) If notification is form employer

• Has a investigation been carried out?

  Yes

  No

  N/A

• Was a significant hazard involved

  Yes

  No

  N/A

16) Environmental damage

17) Plant damage

Name and position

• Signature

  Sign