Particulars of incident:
Type of incident (please circle below):
Role in the event:
The injured person:
Describe the incident: (space overleaf for diagram if needed)
Describe any illness or injury: What part of the body is affected and how?
Describe any property damage: What damage was caused and how?
Analysis: What do you think caused or contributed to the incident?
Prevention: What action has been taken to prevent a reoccurrence?
Have all preventative actions been reviewed by the Event Management Committee, and implemented?
A & E Hospital:
Type of treatment provided:
Notification and investigation WORKSAFE PHONE: (0800) 030-040 (24 hours)
Worksafe NZ advised by: