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INCIDENT / NEAR MISS REPORT

Report #: IR-001
Date reported: 2026-01-01

Serious incidents must be reported to WorkSafe NZ immediately: 0800 030 040. Do not disturb the scene until WorkSafe gives clearance.

Incident Details

Date and time of incident

Location / site address

Type: ☐ Injury ☐ Near Miss ☐ Property Damage ☐ Environmental

Person(s) Involved

Name / role

Employer / company

Contact number

Description of Incident

Describe exactly what happened, in sequence. Include weather, time, activity being performed, and any equipment involved...

Injuries / Damage

Describe injuries sustained or property/equipment damage...

Immediate Actions Taken

First aid administered, emergency services called, area isolated, WorkSafe notified (if applicable)...

Root Cause / Contributing Factors

Identify why the incident occurred — unsafe conditions, procedure not followed, inadequate training, equipment failure...

Corrective Actions

What changes will prevent recurrence? Who is responsible? Due date?

Completed by / Date

Supervisor / PCBU sign-off / Date

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🚨 Incident & Near Miss Report