Incident Reporting Template
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1INCIDENT REPORTING
PRFA100
Department & Location
Time of Incident:
Incident Date:
Injured Employee Name :
Time started Shift:
Date of Report:
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Type of Incident
Injury
Change
Hazard
Incident
Illness
Near Miss
Complaint
Equipment Damage
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Vehicle Accident
Discomfort /Early Reporting
Positive Feedback
Fire Related Incident
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Treatment
First Aid
Doctor
Hospital
Nil
EMPLOYMENT STATUS (tick appropriate box) Permanent
Fixed Term
Contractor
Other
(please state)
8.
Description of Event: (please describe your interpretation of events)
Discomfort/Injury Details – Body Part
Discomfort/Injury Type (tick)
Incident Notification:
Severity:
1.
Sever pain
2.
Pain
Zone Manager Notified
3.
Mild pain
Severity Scale
4.
Discomfort
PRFA Chief Executive Notified
Duration
Stakeholder PCBU Notified
A.
Discomfort/Pain is always
present to some degree
Work Safe NZ – Notifiable Event
B.
Discomfort/pain stays after
Duration Scale
work but improves after a
night’s rest
C.
Only at work
D.
Occasional
Signature of Person Reporting Incident: _____________________________
Date: _________________________
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Parent category: Business