Employee Incident Report Form Template for New Zealand

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Key Requirements PROMPT example:

Employee Incident Report Form

"I need a comprehensive Employee Incident Report Form for our construction company that includes detailed sections for equipment failure and hazardous materials exposure, with specific consideration for WorkSafe NZ reporting requirements and integration with our digital safety management system."

Document background
The Employee Incident Report Form is a crucial document required under New Zealand's health and safety legislation, particularly the Health and Safety at Work Act 2015. This form must be used whenever a workplace incident, accident, or near-miss occurs, regardless of severity. It serves multiple purposes: documenting the incident details for internal records, supporting WorkSafe NZ notifications for notifiable events, facilitating ACC claims when required, and contributing to workplace health and safety improvement initiatives. The form captures vital information including incident details, witness accounts, immediate actions taken, and management review, enabling organizations to meet their legal obligations while maintaining a safe working environment. Regular use of this form helps identify patterns and potential hazards, supporting proactive risk management and regulatory compliance.
Suggested Sections

1. Report Identification: Unique report ID, date and time of report completion

2. Employee Information: Details of the person involved in the incident including name, position, department, and contact information

3. Incident Details: Date, time, and location of the incident

4. Incident Description: Detailed account of what happened, including sequence of events

5. Injury/Damage Information: Description of any injuries sustained or property damage

6. Immediate Actions Taken: Steps taken immediately following the incident, including first aid or emergency response

7. Witnesses: Names and contact details of any witnesses to the incident

8. Reporter Information: Details of the person completing the report if different from the affected employee

9. Manager/Supervisor Review: Section for immediate supervisor or manager to review and comment on the incident

10. Health and Safety Representative Review: Input from workplace health and safety representative

Optional Sections

1. Environmental Conditions: Details about weather, lighting, or environmental factors if relevant to the incident

2. Equipment Involved: Details of any machinery, tools, or equipment involved in the incident

3. Hazardous Materials: Information about any hazardous substances involved in the incident

4. Third Party Details: Information about any non-employees involved in the incident

5. Medical Treatment Details: Specific information about medical treatment if required

6. Previous Related Incidents: Information about any similar incidents that have occurred in the past

7. ACC Claim Details: Section for recording ACC claim information if applicable

Suggested Schedules

1. Witness Statement Form: Template for collecting detailed statements from witnesses

2. Body Diagram: Diagram for marking location and type of injuries

3. Site/Location Map: Space for drawing or attaching a map showing where the incident occurred

4. Photo Log: Template for cataloging and describing any photos taken of the incident scene

5. Risk Assessment Matrix: Tool for assessing the severity and likelihood of similar incidents

6. Investigation Checklist: Checklist for ensuring all necessary investigation steps are completed

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Relevant legal definitions
Relevant Industries

Manufacturing

Construction

Healthcare

Retail

Hospitality

Transportation

Agriculture

Mining

Education

Professional Services

Logistics

Technology

Energy

Tourism

Financial Services

Relevant Teams

Health and Safety

Human Resources

Operations

Risk Management

Compliance

Legal

Senior Management

Facility Management

Employee Relations

Emergency Response

Relevant Roles

Chief Executive Officer

Health and Safety Manager

Human Resources Director

Department Manager

Supervisor

Safety Officer

Risk Management Officer

Operations Manager

Site Manager

Facility Manager

Team Leader

Employee Relations Manager

Compliance Officer

WorkSafe Representative

First Aid Officer

Industries
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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