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NZ Workplace Incident Report Template

This incident report summarizes an event that occurred on [DATE] at [LOCATION]. It describes the type of incident, those involved or affected, details of what happened, potential causes, actions taken to prevent recurrence, and follow up treatment and investigation. The event management committee reviewed preventative actions and the risk register was updated.

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Jovy Dela Merced Garcia
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154 views1 page

NZ Workplace Incident Report Template

This incident report summarizes an event that occurred on [DATE] at [LOCATION]. It describes the type of incident, those involved or affected, details of what happened, potential causes, actions taken to prevent recurrence, and follow up treatment and investigation. The event management committee reviewed preventative actions and the risk register was updated.

Uploaded by

Jovy Dela Merced Garcia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

<INSERT EVENT NAME>

Incident Report
Particulars of incident:
Date: Time: Location:
Type of incident (please circle below):
Injury Illness Environmental Notifiable event Other:
Reported by: Phone:
Role in the event: Email:
The injured person:
Name: Address:
Age: Phone:
Witness(s):
Name: Phone:
Name: Phone:
Name: Phone:
Describe the incident: (space overleaf for diagram if needed)

Describe any illness or injury: What part of the body is affected and how?

Describe any property damage: What damage was caused and how?

Analysis: What do you think caused or contributed to the incident?

Prevention: What action has been taken to prevent a reoccurrence?

Have all preventative actions been reviewed by the Event Management Committee, and implemented?
Yes No
<Event Management Committee> Signature: Date completed:
Treatment:
A & E Hospital: Doctor:
Type of treatment provided:
Notification and investigation WORKSAFE PHONE: (0800) 030-040 (24 hours)
Worksafe NZ advised by: Date:
Investigation conducted by: Date:
Risk Register updated by: Date:

In the event of a notifiable event, you must complete an incident investigation and submit it to Worksafe NZ

<INSERT EVENT NAME> Incident Report Particulars of incident: Date: Time: Location: Type of incident (please circle be

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