Title Page
Report Writer:
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Your Name:
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Department Manager Name:
- Ross Kronfeld
- Gary Oliver
- Allan Richards
- Jason Gibbs
- Kate Fitzgerald
- Paul Soffe
- Ted Glasgow
- Thomas Tanoa
- Mike Thompson
- Albert Rodrigues
- Benjamin Hills
- Greg McCutchan
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Your Signature:
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Date of Report:
Event Reports help others to understand what has happened and may prevent this type of event from happening again - relevant and correct details are important!
Event Details
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Job Number:
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Client / Customer:
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Site Supervisor:
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Date & Time of Event:
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Event Location:
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Who was involved?
- Employees
- Other Contractors
- Visitors
- 3rd Parties
- Witnesses
- Other
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Full name and role
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Name and Company
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Name and Contact
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Name and Contact
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Name and Contact
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What happened?
- Any Injuries?
- Any damage to property?
- Any damage to tools & equipment?
- Any damage to vehicles?
- Any harm to environment?
- Any damage to 3rd party property?
- Any complements?
- Any complaints?
- Any Health and Safety audit issues?
- Any Hazards to report?
- Any opportunities for improvement (OFI's)
- Any quality issues?
- Any close calls/ near misses?
- Other
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What has been done already to manage the event - injury management, scene preserved, emergency services notified, site secured, Manager notified?
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Why do you think this happened?
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How do you think this could have been prevented?
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What documentation has been collected so far to help with the event management?
- JSEA
- Permit/Authority to work
- Job details/scope
- Photos taken/attached
- Medical Certificates
- Names and contact details
- Insurance Form
- Vehicle details
- Other
Injury Details - (Contact Manager/HSEQ asap if medical treatment for a workplace injury)
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Description of injuries: (Remember to escort electric shock victims to get an ECG)
- N/A
- Non-Treatment Injury (NTI)
- First Aid Injury (FAI)
- Medical Treatment Injury (MTI)
- Restricted Work Injury (RWI)
- Lost Time Injury (LTI)
- Fatality (FAT)
- Illness
Important: All operational matters must be reported to your Supervisor. Please send your completed form to HSEQ - erika.p@npe-tech.co.nz
Department Manager/ Person who assigned the job to complete this section
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Describe what else is required to manage this event - stop work/stand-down, follow up investigation, injury management, client liaison, D&A test, insurance claim form, reward presentation, other
- Stop work/ Stand down
- Follow up investigation
- Injury management
- Client liaison
- Drug and Alcohol screening
- Insurance claim form
- Reward presentation
- Other
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Suggestions to improve performance - methodology, job information, training, resources, H&S meeting, other?
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Department Manager- Signature:
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Date:
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HSEQ - Signature:
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Date:
HSEQ will provide guidance and support as required - please contact erika.p@npe-tech.co.nz /mark@npe-tech.co.nz
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HSEQ Event Number:
