Lone worker incident report form

Every incident and near miss involving a lone worker should produce one of these within 24 hours. The form captures the facts while they are fresh, prompts the regulator-notification check, and turns the incident into corrective actions with owners.

Who it's for: Any worker or supervisor reporting an incident, near miss or dangerous occurrence involving lone work.

Free to use and adapt · Last updated 2026-07-21 · No email required

Report details

Reported by (name and role)

Date and time of report

Worker involved (name and role)

Was the worker alone at the time?

Incident details

Date and time of incident

Exact location Address, site area, or GPS coordinates for remote locations

Physical assault or attempted assault
Verbal aggression or threat
Injury or medical event
Near miss (no harm, but could have caused it)
Missed check-in or failed welfare check
Vehicle incident
Property damage or theft
Environmental exposure (heat, terrain, animal)

What happened

Describe the sequence of events in plain language: what the worker was doing, what happened, and how it ended. Stick to facts you know; note anything unconfirmed as unconfirmed. Include what the worker did in response and whether a duress alarm, safety app or check-in system was activated, and what the response was.

People involved and witnesses

Name	Role (worker, client, member of public, witness)	Contact details	Statement taken?

Immediate actions taken

First aid provided
Emergency services called (111)
Worker moved to a safe location
Manager notified
Scene made safe or secured
Client record flagged
Worker offered support (EAP, debrief)

Notifiable incident check

Some incidents must be reported to WorkSafe New Zealand, including deaths, serious injuries or illnesses, and dangerous occurrences as defined under the Health and Safety at Work Act 2015. If in doubt, check the criteria before the end of the day. Notification deadlines are short and non-negotiable, and the site of a notifiable incident may need to be preserved.

Notifiable? [Yes / No]. If yes: notified by [name] on [date/time], reference number [___].

Corrective actions

Action	Owner	Due date	Completed

Sign-off

Reviewed by (manager name and signature)

Date reviewed

Risk assessment updated? Every incident should trigger a review of the relevant lone worker risk assessment

How to use it

Getting the most out of this template

Report near misses with the same discipline as injuries. They are the cheapest safety data you will ever collect.
Complete the form within 24 hours while details are fresh, even if the investigation continues afterwards.
Run the notifiable-incident check the same day. Regulator deadlines are measured in hours for the most serious categories.
Close the loop: an incident report without corrective actions and an updated risk assessment is just paperwork.

This template is general information, not legal advice. Requirements differ by jurisdiction and industry; check the guidance published by WorkSafe New Zealand and seek advice for your specific circumstances.

Questions

Frequently asked

What counts as a notifiable incident?

Broadly: deaths, injuries or illnesses requiring hospital treatment, and dangerous occurrences that could have killed or seriously injured someone. The exact definitions are set under the Health and Safety at Work Act 2015. Check the criteria published by WorkSafe New Zealand the same day the incident occurs.

Should near misses be reported on this form?

Yes. A near miss is the same event as an injury minus the luck. Near-miss reports let you fix the control gap before it costs someone.

Who investigates the incident?

The line manager reviews and signs off every report. Serious incidents should be investigated by someone independent of the immediate team, with worker involvement.

The template covers the paperwork. Duress covers the response.

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