| Complete in the case of an event which is non-notifiable i.e. incident or near miss | |||||||||||
| Complete the following form in the case of a Notifiable Event worksafe.govt.nz/notify-worksafe | |||||||||||
| Particulars of event | |||||||||||
| Date of incident | Time | Reported by | Location | Date reported | |||||||
| The injured person | |||||||||||
| Name Date of Birth Sex (M/F) | |||||||||||
| Address | |||||||||||
| Occupation Period of employment Hours worked since arrival | |||||||||||
| The incident | |||||||||||
| Description | |||||||||||
| Describe what happened | |||||||||||
| x | |||||||||||
| x | |||||||||||
| x | |||||||||||
| x | |||||||||||
| x | |||||||||||
| x | |||||||||||
| Body Part affected | |||||||||||
| ☐ Head | ☐ Neck | ☐ Trunk | ☐ Upper Limb | ☐ Multiple location | ☐ Internal | ||||||
| Nature of injury/disease | |||||||||||
| ☐ Superficial | ☐ Wound | ☐ Sprain/strain | ☐ Bruise/crushing | ☐ Foreign body | ☐ Burn | ||||||
| ☐ Other – | |||||||||||
| Treatment | |||||||||||
| ☐ None | ☐ First Aid only | ☐ Doctor | ☐ Hospital | ☐ N/A | |||||||
| If hospitalisation is required, you will need to complete an online Notifiable Event form (see website link above) | |||||||||||
| Mechanism of incident | |||||||||||
| ☐ Fall, trip, slip | ☐ Heat, energy | ☐ Radiation | ☐ Sound, pressure | ☐ Chemicals | ☐ Substances | ||||||
| ☐ Hitting object | ☐ Body stress | ☐ Mental stress | ☐ Biological | ☐ Other | |||||||
| Agency of incident | |||||||||||
| ☐ Machinery | ☐ Mobile plant | ☐ Transport | ☐ Tool – Powered | ☐ Non-powered | ☐ Chemical | ||||||
| ☐ Material | ☐ Substance | ☐ Environment | ☐ Biological | ☐ Bacteria/virus | ☐ Other | ||||||
| Investigation of incident | |||||||||||
| Investigated by | Signature | Position | Date | ||||||||
