The Hazard Incident Report Form is a crucial document required under New Zealand's workplace health and safety framework, specifically aligned with the Health and Safety at Work Act 2015 and WorkSafe NZ guidelines. This form must be completed whenever a workplace incident, accident, near-miss, or hazardous situation occurs, serving as an official record and investigation tool. It captures essential information about the incident, affected parties, immediate responses, and corrective actions, while facilitating regulatory compliance and supporting continuous improvement in workplace safety practices. The document is designed to ensure thorough incident documentation, support ACC claims where necessary, and provide evidence of due diligence in workplace safety management.
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1. Report Details: Date, time, and location of report completion, report reference number
2. Incident Overview: Basic details including date, time, and location of the incident
3. Reporter Information: Details of the person completing the report including name, role, contact information
4. Incident Type Classification: Classification of the incident (injury, near-miss, property damage, environmental, etc.)
5. Incident Description: Detailed narrative of what happened, including sequence of events
6. Affected Persons: Information about all persons involved or affected by the incident
7. Immediate Actions Taken: Description of immediate responses and actions taken following the incident
8. Witness Details: Names and contact information of witnesses to the incident
9. Risk Assessment: Assessment of the severity and likelihood of recurrence
10. Root Cause Analysis: Investigation into the fundamental causes of the incident
11. Corrective Actions: Planned or implemented actions to prevent recurrence
12. Management Review: Section for management acknowledgment and sign-off
1. Environmental Impact: Section for documenting environmental effects, used when incident involves environmental hazards
2. Equipment/Property Damage: Detailed section for recording damage to equipment or property, used when physical assets are affected
3. Hazardous Substances: Special section for incidents involving dangerous goods or hazardous materials
4. Medical Treatment Details: Additional section for recording medical attention provided, used for injury-related incidents
5. Contractor Involvement: Section for documenting contractor details and responsibilities, used when contractors are involved
6. Regulatory Notification: Section for recording notifications to WorkSafe NZ or other authorities, used for notifiable incidents
7. ACC Claim Details: Section for recording ACC claim information, used when incident results in injury requiring ACC involvement
1. Incident Scene Photographs: Appendix for attaching photographs or diagrams of the incident scene
2. Witness Statements: Detailed written accounts from witnesses
3. Risk Assessment Matrix: Standard risk assessment tool for evaluating incident severity and likelihood
4. Investigation Documentation: Additional investigation reports, test results, or expert assessments
5. Training Records: Relevant training certificates or records related to the incident
6. Equipment Certification: Relevant equipment certification or maintenance records
7. Medical Reports: Attached medical certificates or treatment reports (if applicable)
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