Report details
Reported by (name and role)
Date and time of incident
Date and time reported Report within 24 hours wherever possible
Exact location Site, building, room, aisle or vehicle registration
Incident type Injury, illness, near miss, property damage, dangerous occurrence, violence or aggression
What happened
Description of the incident Facts only, in time order. What was the person doing, what went wrong, what happened next. No blame, no speculation
Equipment, substances or vehicles involved Include asset numbers or registrations if known
Conditions at the time Lighting, weather, floor surface, noise, time pressure, staffing level
People involved
| Name | Role | Involvement (injured, involved, witness) | Contact details |
|---|---|---|---|
Injury and treatment
Nature of injury or illness e.g. laceration to left forearm, suspected sprain. Leave blank for a near miss
Treatment given First aid on site, ambulance called on 111, sent to hospital, GP referral, none
Treated by Name of first aider or attending service
Did the worker stop work? Returned same shift, sent home, expected days off
Immediate actions taken
Tick everything done at the time. These are stopgaps, not the fix. The fix goes in the corrective actions table.
- Area made safe or cordoned off
- Equipment tagged out of service
- Spill contained or cleaned up
- First aid provided
- Emergency services called on 111
- Supervisor or manager notified
- Scene preserved for investigation (serious incidents)
- Witnesses identified and details recorded
- Photographs taken of the scene
- Affected worker's next of kin contacted, where appropriate
Contributing factors
Look past the obvious cause. Most incidents have more than one factor, and the useful ones are usually about the system, not the person.
- Task: unclear procedure, shortcut taken, task not covered by training
- Equipment: faulty, poorly maintained, wrong tool for the job, guard removed
- Environment: housekeeping, lighting, weather, layout, congestion
- People: fatigue, inexperience, time pressure, working alone
- Organisation: staffing levels, communication gaps, missing or outdated risk assessment
Corrective actions and sign off
Every incident record should end in at least one action, even a near miss. If the answer is genuinely nothing needs to change, record why.
| Corrective action | Owner | Due date | Date completed |
|---|---|---|---|
Reviewed by [manager] on [date]. Notifiable to WorkSafe New Zealand: yes / no. If yes, notified on [date] by [name]. Linked risk assessment updated: yes / no / not required.