TDE HS Form 12.0 Incident Report

• Document No.

• Incident Location / Address

• Incident Date / Time

  Date

• Client / Principal Contractor

• Form Completed by

INCIDENT DETAILS

• Client / Principal Contractor

  Select

• What happened? Describe the incident and the response

• Include any photos of the incident scene if possible

  Media

• Incident Type

  Select Property damage Close call (no injury or damage) Injury not requiring treatment Injury requiring on site first aid Injury requiring medical treatment Work-related health event Fatality

  • Property damage
  • Close call (no injury or damage)
  • Injury not requiring treatment
  • Injury requiring on site first aid
  • Injury requiring medical treatment
  • Work-related health event
  • Fatality

• Check if this event is notifiable at the link
  http://www.worksafe.govt.nz/worksafe/notifications-forms/notifiable-events

• Is this a notifiable event?

  Yes

  No

  Not Applicable

PROPERTY DAMAGE DETAILS

• Was any property damage caused?

  Yes

  No

  Not Applicable

• What property was damaged?

• How did the damage occur?

• Please upload photos of the damage if possible

  Media

INJURY DETAILS

• Was any person injured (including illness/harm to health)?

  Yes

  No

  Not Applicable

• The injured is a

  TDE Employee

  TDE Subcontractor

  Other contractor (not engaged by TDE)

  Member of the public / private client

  Other (add notes)

• DETAILS OF THE INJURED PERSON

• Date of birth (DD/MM/YYYY)

• Full name

• Employer (if applicable)

• Job title (if applicable)

• Home address (if you can get it)

• Contact phone numbers (if you can get them)

• Email address (if you can get it)

• Approximately how long has the injured been employed in their current role? (if applicable)

• Approximately how many hours had the injured been working prior to the incident? (if applicable)

• DETAILS OF THE INJURY

• Add each injury separately

Injury

• What body part was injured?

  Select Head / Face Eyes / vision Inner ear (hearing loss) Neck Back Torso / chest Left arm, elbow or shoulder Right arm, elbow or shoulder Left hand or fingers Right hand or fingers Left leg or knee Right leg or knee Left foot or ankle Right foot or ankle Respiratory system Other internal organ Mental harm Other (describe in notes)

  • Head / Face
  • Eyes / vision
  • Inner ear (hearing loss)
  • Neck
  • Back
  • Torso / chest
  • Left arm, elbow or shoulder
  • Right arm, elbow or shoulder
  • Left hand or fingers
  • Right hand or fingers
  • Left leg or knee
  • Right leg or knee
  • Left foot or ankle
  • Right foot or ankle
  • Respiratory system
  • Other internal organ
  • Mental harm
  • Other (describe in notes)

• What type of injury was it?

  Select Strain / sprain / discomfort Fracture / broken bone Dislocation Laceration / cut Foreign body Chemical reaction Burn / scald Bruising Scratch / graze / abrasion Amputation Concussion Work related illness / disease / allergic reaction / medical event Medical event (not caused by work) Other (describe in notes)

  • Strain / sprain / discomfort
  • Fracture / broken bone
  • Dislocation
  • Laceration / cut
  • Foreign body
  • Chemical reaction
  • Burn / scald
  • Bruising
  • Scratch / graze / abrasion
  • Amputation
  • Concussion
  • Work related illness / disease / allergic reaction / medical event
  • Medical event (not caused by work)
  • Other (describe in notes)

• Add photos if possible (check injured person is OK with this)

  Media

INCIDENT RESPONSE DETAILS

• What immediate corrective and preventative actions have you taken to control the hazard and prevent further harm?

• What other actions need to be taken?

• All incidents must be reported to TDE as soon as practicable. Serious incidents MUST be reported to a director URGENTLY. Directors will determine if Worksafe NZ needs to be notified, investigation requirements, and other actions necessary.

• Is this a serious incident?

  Yes

  No

  Not Applicable

• Who have you reported it to?

  Dan Sincock

  Jason Shields

  Shelley Sincock

  Unable to contact anyone

• How did you notify them?

  Select Phone call Text Message In person Email Other (describe in notes)

  • Phone call
  • Text Message
  • In person
  • Email
  • Other (describe in notes)

• Approximately when did you notify them?

  Date