Incident report form (NZ)
This incident report form NZ replaces the old serious harm workplace form. Use it to record any workplace incident properly: what happened, who was involved, injuries and treatment, whether it is a NOTIFIABLE EVENT under HSWA 2015 (a death, a notifiable injury or illness, or a notifiable incident) that must be notified to WorkSafe New Zealand as soon as possible, and the corrective actions so it does not happen again.
Incident report form (NZ)
Company: ____________
Site: ____________
Date: ____________
Incident details
| Date and time of incident: ____________ | N/A · Action | |
| Exact location on site: ____________ | N/A · Action | |
| Project / main contractor: ____________ | N/A · Action | |
| Task being performed at the time: ____________ | N/A · Action | |
| Plant, equipment or substances involved: ____________ | N/A · Action |
People
| Injured or involved person(s), company and role: ____________ | N/A · Action | |
| Supervisor notified (name, time): ____________ | N/A · Action | |
| First aider who responded: ____________ | N/A · Action |
What happened
| Describe the sequence of events (attach a page if needed) | N/A · Action | |
| PPE being worn at the time | N/A · Action | |
| Site or weather conditions relevant to the incident | N/A · Action |
Injury and treatment
| Nature of injury and body part (if any) | N/A · Action | |
| First aid given on site | N/A · Action | |
| Taken to hospital / medical treatment required | N/A · Action | |
| Time off work expected | N/A · Action |
Is it a NOTIFIABLE EVENT? (tick any that apply)
| A death | N/A · Action | |
| A notifiable injury or illness (serious harm requiring immediate treatment or hospitalisation) | N/A · Action | |
| A notifiable incident (an unplanned event exposing people to a serious risk, such as a collapse, an uncontrolled release of energy, or a fall of plant) | N/A · Action | |
| IF ANY TICKED: notify WorkSafe New Zealand AS SOON AS POSSIBLE, and do not disturb the scene except to help an injured person or make the site safe, until WorkSafe says otherwise | N/A · Action |
Notification record (if notifiable)
| WorkSafe notified (by whom, method, time, reference): ____________ | N/A · Action | |
| Scene preserved from (time): ____________ | N/A · Action | |
| Written record of the event kept (required: keep records of notifiable events for at least 5 years) | N/A · Action |
Witnesses and evidence
| Witness names and contact details: ____________ | N/A · Action | |
| Photos taken of the scene | N/A · Action | |
| Statements collected | N/A · Action |
Causes and corrective actions
| Immediate cause: ____________ | N/A · Action | |
| Contributing factors (training, controls, conditions): ____________ | N/A · Action | |
| Corrective actions, owner and due date: ____________ | N/A · Action | |
| SSSP and task analyses for this work reviewed before work resumed | N/A · Action |
Completed by: ____________________
Signature: ____________________
swmspack.com · Free printable checklist. Not legal advice; adapt to your site.
An incident is the trigger to review the SSSP before work resumes. Regenerate yours in minutes.
Forms record the day; the SSSP is the plan the main contractor asks for before you start. Generate a site-specific one for your trade, checked against HSWA 2015.
Common questions
▸Is this the old serious harm form?
It does the same job under the current law. "Serious harm" was the term in the Health and Safety in Employment Act 1992. The Health and Safety at Work Act 2015 replaced it with notifiable events (a death, a notifiable injury or illness, or a notifiable incident), and those are what you notify to WorkSafe New Zealand now.
▸Which events must be notified to WorkSafe?
Notifiable events under HSWA 2015: a death, a notifiable injury or illness, and a notifiable incident (an unplanned event exposing people to serious risk). Notify WorkSafe New Zealand as soon as possible after the event.
▸How long do incident records have to be kept?
Records of notifiable events must be kept for at least 5 years. Keep the incident report with them; it is the detail behind the notification.
▸Does an incident mean the SSSP failed?
It means something in the plan did not hold on the day. Review the SSSP and the task analysis for that work with the crew before the work resumes, and record what changed.