Template Information
Created by worksafe new zealand, this accident investigation form can be used to record details of an incident as part of an investigation.
Category: construction
Template Questions
- Name of organisation
- Branch/department
- Date of accident Date
- Time Date
- Location Address
- Date Reported Date
- Name
- Address Address
- Date of birth Date
- Phone number
- Length of employment - at plant
- On job
- Type of injury
- Comments
- Property or material damaged:
- Attach media (if applicable)
- Nature of damage:
- Object/substance causing damage:
- Describe what happened
- What caused the accident?
- How serious could it have been?
- How often is this likely to happen again?
- What action has or will be taken to stop another accident like this happening?
- Description
- Completed?
- By whom
- When Date
- Type of treatment given
- Name of person giving first aid
- Doctor/Hospital
- Accident investigated by
- Signature
- Date Date
- WorkSafe advised?
- Select date Date