NPE-Tech Event Report Form-1

Report Writer:

• Your Name:

• Department Manager Name:

  Select Ross Kronfeld Gary Oliver Allan Richards Jason Gibbs Kate Fitzgerald Paul Soffe Ted Glasgow Thomas Tanoa Mike Thompson Albert Rodrigues Benjamin Hills Greg McCutchan

  • Ross Kronfeld
  • Gary Oliver
  • Allan Richards
  • Jason Gibbs
  • Kate Fitzgerald
  • Paul Soffe
  • Ted Glasgow
  • Thomas Tanoa
  • Mike Thompson
  • Albert Rodrigues
  • Benjamin Hills
  • Greg McCutchan

• Your Signature:

  Sign

• Date of Report:

  Date

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

• Job Number:

• Client / Customer:

• Site Supervisor:

• Date & Time of Event:

  Date

• Event Location:

• Who was involved?

  Select N/A Employees Other Contractors Visitors 3rd Parties Witnesses Other

  • N/A
  • Employees
  • Other Contractors
  • Visitors
  • 3rd Parties
  • Witnesses
  • Other

• Full name and role

• Name and Company

• Name and Contact

• Name and Contact

• Name and Contact

• What happened?

• What has been done already to manage the event - injury management, scene preserved, emergency services notified, site secured, Manager notified, other?

• Why do you think this happened?

• How do you think this could have been prevented?

• What documentation has been collected so far to help with the event management?

  Select JSEA Permit/Authority to work Job details/scope Photos taken/attached Medical Certificates Names and contact details Insurance Form Vehicle details Other

  • 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)

• Description of injuries: (Remember to escort electric shock victims to get an ECG)

  Select 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

  • 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

• 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

  Select Stop work/ Stand down Follow up investigation Injury management Client liaison Drug and Alcohol screening Insurance claim form Reward presentation Other Tools & Equipment repair/replacement

  • Stop work/ Stand down
  • Follow up investigation
  • Injury management
  • Client liaison
  • Drug and Alcohol screening
  • Insurance claim form
  • Reward presentation
  • Other
  • Tools & Equipment repair/replacement

• Please specify/ create action

• Please specify/ create action

• Please specify/ create action

• Please specify / create action

• Please specify/ create action

• Please specify/ create action

• Please specify/ create action

• Please specify/ create action

• Suggestions to improve performance - methodology, job information, training, resources, H&S meeting, other?

• Department Manager- Signature:

  Sign

• Date:

  Date

• HSEQ - Signature:

  Sign

• Date:

  Date

HSEQ will provide guidance and support as required - please contact erika.p@npe-tech.co.nz /mark@npe-tech.co.nz

• HSEQ Event Number: