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Health And Safety Incident Report Form

Health And Safety Incident Report Form Template for New Zealand

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Key Requirements PROMPT example:

Health And Safety Incident Report Form

"I need a comprehensive Health and Safety Incident Report Form for a large construction company with multiple sites, including sections for heavy machinery accidents and specific WorkSafe NZ reporting requirements for high-risk work."

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Document background
The Health and Safety Incident Report Form is a mandatory document required under New Zealand's workplace safety regulations. It must be completed whenever a workplace incident occurs, including accidents, near-misses, or identified hazards that could lead to harm. The form ensures compliance with the Health and Safety at Work Act 2015 and related regulations, while also supporting incident investigation, risk management, and continuous improvement of safety practices. It captures crucial information about the incident, including time, location, persons involved, witness accounts, and immediate actions taken. This documented information is essential for regulatory reporting, ACC claims, trend analysis, and implementing preventive measures. The form should be readily available to all workers and must be completed as soon as practical after an incident occurs.
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 reporting the incident

3. Incident Type Classification: Category of incident (injury, near miss, property damage, environmental, etc.)

4. Affected Person(s) Information: Details of all persons involved, including workers, contractors, visitors, or members of the public

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

6. Immediate Actions Taken: Steps taken immediately after the incident to secure the scene and ensure safety

7. Witness Information: Names and contact details of any witnesses to the incident

8. Initial Assessment: Preliminary evaluation of the incident severity and potential consequences

9. Notifications Made: Record of who has been notified (supervisor, HSE manager, WorkSafe NZ, etc.)

10. Declaration: Signature section confirming the accuracy of the reported information

Optional Sections

1. Medical Treatment Details: To be completed if medical treatment was required, including first aid or professional medical care

2. Environmental Impact: To be included if the incident involved environmental damage or potential environmental risks

3. Equipment/Property Damage: Details of any damage to equipment, vehicles, or property when applicable

4. Risk Assessment: To be included for serious incidents requiring detailed risk evaluation

5. WorkSafe Notification Details: Required for notifiable events as defined in the Health and Safety at Work Act

6. ACC Claim Information: To be completed if the incident requires an ACC claim to be filed

7. External Agency Involvement: Details of any external agency involvement (police, fire service, etc.)

Suggested Schedules

1. Incident Scene Diagram: Template for sketching the incident scene and relevant details

2. Incident Investigation Form: Detailed form for conducting thorough incident investigation

3. Risk Matrix: Guide for assessing incident severity and likelihood

4. Notification Guidelines: Reference guide for when and how to notify different stakeholders

5. Injury Classification Guide: Reference for correctly classifying types of injuries

6. Corrective Actions Register: Template for recording and tracking required corrective actions

7. Witness Statement Form: Template for collecting detailed witness accounts

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






























Clauses




















Relevant Industries

Construction

Manufacturing

Healthcare

Agriculture

Mining

Transportation

Retail

Hospitality

Education

Professional Services

Logistics

Energy

Technology

Public Sector

Maritime

Aviation

Food Processing

Forestry

Relevant Teams

Health and Safety

Human Resources

Operations

Compliance

Risk Management

Quality Assurance

Production

Facilities Management

Site Operations

Emergency Response

Occupational Health

Legal

Administration

Relevant Roles

Health and Safety Manager

Safety Officer

Site Supervisor

Factory Manager

Human Resources Manager

Operations Manager

Project Manager

Department Head

Line Manager

Compliance Officer

Risk Manager

Safety Representative

Employee Relations Manager

Facility Manager

Site Administrator

Quality Assurance Manager

Production Supervisor

Team Leader

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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