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Critical Incident Report Form

Critical Incident Report Form Template for New Zealand

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Key Requirements PROMPT example:

Critical Incident Report Form

"I need a Critical Incident Report Form for a large healthcare facility in Auckland that complies with both the Health and Safety at Work Act 2015 and healthcare-specific regulations, with additional sections for patient safety incidents and medical staff reporting."

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Document background
The Critical Incident Report Form is a fundamental document required under New Zealand health and safety legislation, particularly the Health and Safety at Work Act 2015. It is designed to be used whenever a significant incident, accident, or near-miss occurs in the workplace. The form must be completed as soon as practicable after an incident, capturing crucial details while they are fresh and ensuring proper notification to relevant authorities when required. It serves multiple purposes: documenting the incident for legal compliance, facilitating internal investigation and response, identifying preventive measures, and supporting insurance or compensation claims if necessary. The document includes sections for immediate response actions, witness statements, and follow-up recommendations, making it an essential tool for risk management and continuous improvement in workplace safety.
Suggested Sections

1. Incident Identifier: Unique reference number, date, time, and location of the incident

2. Reporter Details: Name, role, and contact information of the person completing the report

3. Incident Classification: Type and severity of incident, including whether it's a notifiable incident under the Health and Safety at Work Act 2015

4. Incident Description: Detailed account of what happened, including sequence of events

5. Persons Involved: Details of all people involved, including witnesses, affected parties, and their roles

6. Immediate Actions Taken: Steps taken immediately following the incident to ensure safety and contain the situation

7. Notifications Made: List of parties notified (e.g., emergency services, WorkSafe NZ, management)

8. Initial Risk Assessment: Assessment of immediate risks and hazards identified

9. Contributing Factors: Analysis of factors that may have contributed to the incident

10. Recommendations: Immediate and long-term actions recommended to prevent recurrence

Optional Sections

1. Environmental Impact: Required when incident involves environmental damage or contamination

2. Equipment/Property Damage: To be included when physical assets are damaged during the incident

3. Media/Communications: Required for high-profile incidents requiring public communications

4. Cost Impact: Optional section for documenting financial implications of the incident

5. Business Continuity Measures: Required when incident affects business operations

6. Third Party Involvement: To be included when contractors or external parties are involved

7. Regulatory Compliance: Required for incidents involving regulatory breaches or compliance issues

Suggested Schedules

1. Appendix A: Witness Statements: Template and collected statements from witnesses

2. Appendix B: Photographic Evidence: Photos, diagrams, or visual documentation of the incident

3. Appendix C: Risk Assessment Matrix: Standard risk assessment tool for evaluating incident severity

4. Appendix D: Notification Checklist: Checklist of required notifications based on incident type

5. Appendix E: Investigation Guidelines: Procedures for conducting thorough incident investigations

6. Appendix F: Related Documents: Relevant procedures, permits, or certificates related to the incident

7. Appendix G: Follow-up Action Plan: Template for documenting and tracking corrective actions

Authors

Alex Denne

Head of Growth (Open Source Law) @ ¶¶Òõ¶ÌÊÓƵ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co
Relevant legal definitions






























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Relevant Industries

Manufacturing

Construction

Healthcare

Education

Mining and Resources

Transportation and Logistics

Retail

Hospitality

Agriculture

Energy

Chemical Processing

Telecommunications

Financial Services

Public Sector

Maritime

Aviation

Relevant Teams

Health and Safety

Operations

Human Resources

Risk and Compliance

Quality Assurance

Facilities Management

Security

Emergency Response

Legal

Environmental

Occupational Health

Senior Management

Production

Maintenance

Training and Development

Relevant Roles

Health and Safety Manager

Operations Manager

Site Supervisor

Human Resources Director

Facility Manager

Department Head

Safety Officer

Risk Manager

Compliance Officer

Project Manager

Team Leader

Production Supervisor

Quality Assurance Manager

Environmental Officer

Security Manager

Emergency Response Coordinator

Occupational Health Nurse

Chief Operating Officer

Line Manager

Shift Supervisor

Industries







Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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