Accident Investigation Form

ACCIDENT INVESTIGATION FORM


1.     Particulars of accident
Date of accident:  
Time of accident:  
Location of accident:  
Date reported:  

 

2.  The injured person
Name:
Address:

 

 

Date of birth:
Phone number:
Reason for being at the location:
⃝    Employee ⃝    Visitor ⃝    Contractor
⃝    Volunteer ⃝    Congregation ⃝    Other:
Length of employment (if applicable):  
Injury  
Tick the type of injury: Part of the body affected:
⃝    Laceration/cut  
⃝    Scratch/abrasion  
⃝    Strain/sprain  
⃝    Bruising  
⃝    Foreign body  
⃝    Heat burn/scald  
⃝    Internal injury  
⃝    Dislocation  
⃝    Fracture  
⃝    Poisoning  
⃝    Chemical burn/gas  
⃝    Other (please specify):

 

Type of treatment given:
Name(s) of person or service (e.g. medical centre) giving treatment:

 

 

 

3. Damaged property
Property or material damaged and the nature of damage:
 
 
 
 
 

 

4. The accident
Description    
Describe what happened.

Include a drawing of the event if this was a vehicle accident, or if a picture will help in the investigation and to address the hazard. Please draw on the other side of this form, if needed.

 
 
 
 
 
 
 
 
 
 
 
Analysis    
What caused the accident?
 
 
 
 
 
 
 
 
How serious could it have been?
⃝    Minor ⃝    Serious ⃝    Very serious
If nothing changes, would this incident occur again?
⃝    Rarely ⃝    Occasionally ⃝    Often
Prevention    
What action has been taken to stop another accident like this from happening again?
Action By Whom When
     
     
     
     
     
     
     

 

5. Investigation
Name of person(s) who investigated  incident:
 
 
Have Worksafe been advised? ⃝    YES ⃝    NO
If YES, date of advisement:  

 


NOTES AND EXPLANATORY GUIDANCE

The Health and Safety at Work Act 2015 places requirements on ‘Persons Conducting a Business or Undertaking’ (PCBUs) to record and investigate accidents. The church, as an organisation that employs staff and uses volunteers, is deemed to be a PCBU.

The purpose of the investigation procedure is to determine actual causes of an accident/incident and to put in place procedures or controls to minimise the chances of a recurrence.

 

Serious harm and significant hazards – notifiable incidents

A notifiable incident is where someone’s health or safety is seriously endangered or threatened (or results in death). A notifiable incident also covers incidents which may have only resulted in minor (non-notifiable) injuries but had the potential to cause serious injury, illness or death (i.e. significant hazards).

If the incident is notifiable – that is, it caused serious harm, or the hazard is significant and could cause serious harm – then do not use this form. The correct form to use is the “Form of register or notification of circumstance of accident or serious harm” which is also available at the church office or on the website.

Note: when an incident results in serious harm, WorkSafe NZ must be contacted immediately and the scene must be isolated and protected for inspection.

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