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Welcome to the WRC Incident, Near Miss and Equipment Damage Reporting Form.
Please fill out and submit this form.
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1
Name of Reporter:
First Name
Last Name
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2
Contact Phone Number of Reporter
Phone Number
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3
Are you reporting an incident or a near miss?
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An incident is an event that results in equipment damage or injury. A Near Miss is an event that has the potential to cause equipment damage or injury.
Incident
Near Miss
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4
What was the date and time of the incident?
Please be as specific as possible
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Date
Year
Month
Day
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Minutes
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PM
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5
Incident Location
On Lake Hayes
WRC Boathouse
On Lake Wakatipu
Twizel
Other
On Lake Hayes
WRC Boathouse
On Lake Wakatipu
Twizel
Other
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6
If other, where did the incident occur?
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7
Incident Description
In detail, please describe what happened
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8
Was there an injury?
YES
NO
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9
Who was injured and describe the nature of the injury?
Please list all injured persons in the below form with their injury.
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10
Was there equipment damage?
YES
NO
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11
Please give specific details of the equipment damaged and nature of the damage.
Please list all damage below.
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12
Has the equipment been clearly marked as unusable?
YES
NO
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13
Do you have any further comments?
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14
Date and Time of Near Miss.
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Date
Year
Month
Day
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Hour
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30
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50
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20
30
40
50
Minutes
AM
PM
PM
AM
PM
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15
Near Miss Location
On Lake Hayes
In WRC Boathouse
On Lake Wakatipu
Twizel
Other
On Lake Hayes
In WRC Boathouse
On Lake Wakatipu
Twizel
Other
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16
If other, where did the incident occur?
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17
Near Miss Description
In detail, describe the near miss including the equipment used. If known, include the cause.
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18
What could have happened?
Equipment Damage Only
First Aid Injury
Medical Treatment Injury
Hospitalisation
Long Term Injury
One person dying
More than one person dying
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19
Any further comments.
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20
*
This field is required.
I certify that the aforementioned information is true and correct
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