H&S ACCIDENT / INCIDENT / NEAR MISS Report
This form enables you to report an accident or incident that resulted in an injured person or damaged property. Additionally, this form can be used to report a 'near miss'
Name of person completing this report
*
First Name
Last Name
E-mail
*
Today's Date
-
Day
-
Month
Year
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Was someone injured?
YES
NO
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The Injured Person
Name of injured person
First Name
Last Name
Injured person is a
Staff Member
Student
Visitor to site
Age
Phone number
-
Area Code
Phone Number
Length of time as staff member / student
Less than one month
0 - 6 months
6 - 12 months
12 months +
Injured part of the body
Type of injury
Amputation
Bruising
Burn/Scald
Death
Chemical Reaction requiring medical treatment within 48 hrs
Disclocation
Eye Injury
Foreign Body
Injury or illness requiring immediate hospital admittance
Head injury
Infection
Internal
Laceration / Cut
Loss of bodily functions
Spinal injury
Scratch / Abrasion
Scalping / Degloving
Strain / Sprain
Other
If you chose other in the above box, please indicate the type of injury
Name of person giving first aid
First Name
Last Name
Type of treatment given
Doctor / Hospital
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Damaged Property
Was there damage to property?
YES
NO
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Damaged Property
Describe the property / material that was damaged
Nature of the damaged
Object / substance inflicting damage
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The Accident / Incident / Near Miss
Date of Accident / Incident / Near Miss
*
-
Day
-
Month
Year
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Time of Accident / Incident / Near Miss
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Location of the Accident / Incident / Near Miss
*
Describe what happened
*
If vehicle accident, please upload a drawing / diagram of what occured
Upload a File
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What were the causes of the accident / incident / near miss?
*
How bad COULD it have been?
Fatality
Major Injury
Moderate Injury
Minor Injury
What is the chance of it happening again?
Almost Certain
Highly Likely
Moderate Possibility
Slight Possibility
Rare
What corrective action has or will be taken to prevent a recurrence?
By whom?
Date of action taken or required by
-
Month
-
Day
Year
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Investigative Action - BTI staff to fill in the following section
Accident / Incident / Near Miss investigated by
First Name
Last Name
Date of investigation
-
Day
-
Month
Year
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WorkSafe NZ Advised?
YES
NO
Date
-
Month
-
Day
Year
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Any further comment / information / recommendations
Is a RISK Assessment Required?
YES
NO
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Submit ACCIDENT / INCIDENT / NEAR MISS Investigation
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