| Particulars of incident |
| Date of incident |
Time |
Reported by |
Location |
Date reported |
| The injured person |
| For details on injured parties refer to page 3.4 |
| The incident |
| Description |
| Describe what happened |
| x |
| x |
| x |
| x |
| x |
| x |
| x |
| Analysis |
| What were the causes of the incident? |
| x |
| x |
| x |
| x |
| Potential severity of the incident |
Chance of a reoccurrence |
| ☐ Serious |
☐ Potential Harm |
☐ Minor |
☐ Major |
☐ Occasional |
☐ Rare |
| Prevention |
| Actions taken to prevent a recurrence? Tick items already actioned |
|
By whom |
When |
| x |
|
|
|
| x |
|
|
|
| x |
|
|
|
| x |
|
|
|
| x |
|
|
|
| Risk register updated Y/N |
Effectiveness of corrective actions taken is approved Y/N |
| Treatment and investigation of incident |
| Investigated by |
Signature |
Position
|
Date |
| Type of treatment given |
Doctor/Hospital |
WORKSAFE NZ Notified Y/N |
Date |
