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🚨 Incident & Near Miss Report
Document workplace incidents, injuries, and near misses — required under HSWA 2015 for notifiable incidents.
How to use: Report all incidents within 24 hours. Notify WorkSafe NZ immediately for serious incidents. All fields are editable — click any text to change it.
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INCIDENT / NEAR MISS REPORT
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