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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."
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
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
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
Accident
Near Miss
Notifiable Event
Notifiable Injury
Notifiable Illness
Notifiable Incident
Affected Person
PCBU (Person Conducting a Business
Worker
Workplace
Health and Safety Representative
First Aid
Hazard
Risk
Control Measure
Reasonably Practicable
Serious Harm
Critical Risk
Emergency Response
WorkSafe NZ
ACC (Accident Compensation Corporation)
Root Cause
Contributing Factor
Immediate Action
Corrective Action
Preventive Action
Personal Protective Equipment (PPE)
Safe Work Procedure
Investigation
Personal Information
Incident Details
Injury Description
Property Damage
Witness Information
Health and Safety
Emergency Response
Medical Treatment
Privacy and Confidentiality
Management Review
Investigation Details
Risk Assessment
Corrective Actions
Regulatory Reporting
Record Keeping
WorkSafe Notification
ACC Claims
Follow-up Actions
Documentation Requirements
Manufacturing
Construction
Healthcare
Retail
Hospitality
Transportation
Agriculture
Mining
Education
Professional Services
Logistics
Technology
Energy
Tourism
Financial Services
Health and Safety
Human Resources
Operations
Risk Management
Compliance
Legal
Senior Management
Facility Management
Employee Relations
Emergency Response
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
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