Work Place Injury Report Form Template for New Zealand

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Key Requirements PROMPT example:

Work Place Injury Report Form

"I need a comprehensive Workplace Injury Report Form for our construction company that includes specific sections for heavy machinery incidents and working at heights, while ensuring compliance with New Zealand's Health and Safety at Work Act 2015 and WorkSafe NZ requirements."

Document background

The Work Place Injury Report Form is a crucial document required under New Zealand's health and safety legislation, specifically the Health and Safety at Work Act 2015 and related regulations. This form must be completed whenever a workplace injury or incident occurs, regardless of severity. It serves multiple purposes: documenting the incident details, tracking injury patterns, facilitating ACC claims, meeting WorkSafe NZ reporting requirements, and supporting injury prevention initiatives. The form should be completed as soon as practicable after an incident occurs and must be maintained as part of the organization's health and safety records. It contains sections for recording essential information about the injured person, incident details, witness accounts, immediate actions taken, and follow-up measures implemented.

Suggested Sections

1. Report Identification: Form ID, date of report, and type of report (initial/follow-up)

2. Injured Person Details: Full name, contact information, date of birth, employee ID, role, department, and employment status

3. Incident Details: Date, time, and location of incident, what happened, type of injury, body part(s) affected

4. Incident Location and Circumstances: Specific details about where and how the incident occurred, including any equipment or materials involved

5. Immediate Response: First aid or medical treatment provided, who provided it, and immediate actions taken

6. Witness Information: Names and contact details of any witnesses to the incident

7. Manager/Supervisor Review: Immediate supervisor's assessment and initial response to the incident

8. Investigation Details: Contributing factors, root cause analysis, and findings

9. Corrective Actions: Actions taken or planned to prevent similar incidents

10. Medical Information: Treatment provider details, diagnosis, and treatment plan

11. Return to Work: Current work status and return to work arrangements

12. Sign-off: Signatures of injured person, supervisor, and health and safety representative

Optional Sections

1. Notifiable Event Details: Additional information required if the incident meets WorkSafe NZ's notifiable event criteria

2. Third Party Involvement: Details of any third parties involved in the incident (contractors, visitors, public)

3. Equipment/Machinery Details: Specific information about equipment involved in the incident, including maintenance records

4. Hazardous Substances: Details required when incident involves hazardous substances

5. Mental Health Impact: Assessment of psychological impact when incident involves trauma or stress

6. External Agency Notifications: Records of notifications to WorkSafe NZ, ACC, or other regulatory bodies

Suggested Schedules

1. Incident Scene Photographs: Visual documentation of the incident scene, equipment, or injuries

2. Medical Certificates: Copies of medical certificates and treatment records

3. Risk Assessment: Completed risk assessment forms related to the activity

4. Training Records: Relevant training and competency records of involved parties

5. ACC Forms: Copies of ACC claim forms and correspondence

6. Investigation Report: Detailed investigation findings and recommendations

7. Witness Statements: Written statements from witnesses

8. Safety Data Sheets: If incident involves hazardous substances

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

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Construction

Manufacturing

Agriculture

Mining

Healthcare

Retail

Hospitality

Transportation

Warehousing

Education

Professional Services

Energy

Forestry

Maritime

Aviation

Public Service

Chemical Industry

Food Processing

Waste Management

Telecommunications

Relevant Teams

Health and Safety

Human Resources

Operations

Risk Management

Compliance

Quality Assurance

Facilities Management

Production

Maintenance

Security

Emergency Response

Occupational Health

Legal

Training and Development

Senior Management

Relevant Roles

Health and Safety Manager

HR Director

Operations Manager

Site Supervisor

Factory Manager

Construction Site Manager

Line Manager

Department Head

Safety Officer

Risk Manager

Compliance Officer

Project Manager

Shift Supervisor

Plant Manager

Store Manager

Office Manager

Field Supervisor

Workshop Manager

Principal

Chief Executive Officer

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Let's create your Work Place Injury Report Form

Authors

Alex Denne

Find the exact document you need

Health And Safety Incident Report Form

Hazard Incident Report Form

Work Place Injury Report Form

Employee Incident Report Form

Critical Incident Report Form

Security Incident Report Form

Incident Response Form

Incident Investigation Form

Download our whitepaper on the future of AI in Legal

Genie’s Security Promise

Your documents are private:

Your documents are protected:

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Innovation in privacy:

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