Incident Reporting

Incident Reporting Form

Date of incident:

Select Contract:

Location of incident:

Injury type:

Fatality (Injury Class 1, Reporting: immediately)

Notifiable injury, illness or incident (Injury Class 1, Reporting: immediately)

Lost time injury (Injury Class 2, Reporting: <24 hours)

Medical treatment (Injury Class 2, Reporting: <48 hours)

Summary of events

Persons involved in the incident

Immediate cause of incident

Underlying cause of incident

Root cause of incident

Immediate action taken

Human factors

Outcome of incident, e.g. severity of harm caused, injury, damage

Corrective actions with clearly defined timelines and people responsible for implementation

Details of what support is provided to the injured person(s), other workers and family (if required)

Recommendations for further improvement

Captcha:

Halafononga ki ha Ngātai Tu’uloa Tonga