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Incident/Injury Form
Date/Time Occurred *
Location *
Select Location...
Albany
Auckland Airport
Auckland Uni
Christchurch Central
Glenfield
Hamilton
Head Office - Assembly
Head Office - Other
Head Office - RA
Head Office - Service
Head Office - Warehouse
Henderson
Hornby
Lambie Drive - Warehouse
Manukau
Mi Store - Sylvia Park
New Plymouth
Newmarket
Other
Palmerston North
Penrose
Petone
Queen Street
Ryan Place Office - Downstairs
Ryan Place Office - Kitchenette
Ryan Place Office - Other
Ryan Place Office - Upstairs
St Lukes
Tauranga
Wellington
Westgate
First Name
Last Name
Specific Area *
Parties Involved *
Type *
Illness
Injury
Incident
Near Miss
Injury Category
Minor Injury - No First Aid
First Aid
Medical Treatment
Lost Time
Illness Category
No First Aid
First Aid
Medical Treatment / Emergency Services Involved
Illness Type
Nausea
Faint/ Light Headed
Asthma
Seizure
Stroke
Heart Attack
Allergic Reaction
Other
Incident Category
Minor Impact, No Damage
Minor Damage/ Repair Required
Tag Out Equipment/ Isolate Area
Critical Damage, Requires Immediate Attention
Incident Type
Equipment Malfunction
Damage to Equipment
Hazardous Substance Spill
Damage to Building/ Property
Pallet/ Stock Falling from Forklift
Pallet Falling from Racking
Vehicle/ Mobile Plant
Other
Near Miss Category
Potential damage
Potential Injury
Potential Damage & Injury
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Email Address
Event (What happened during the event?) *
Post-Event (What happened after the event?) *
Affected Persons Name
Persons Status
Staff Member
Customer
Contractor
Delivery Driver
Visitor
Other
Medical Treatment
Doctor, hospital, physio?
Lost Time?
First Aid?
Is there an ACC Claim or Medical Certificate? *
Yes
No
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Mark Injury
Body part injured?
Type of injury
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Clear Area
Body part injured?
Head
Wrist
Neck
Hand
Shoulder
Leg
Torso / Stomach
Knee
Back
Arm
Ankle
Elbow
Foot
Other
Type of injury
Bruising
Concussion
Sprain/Strain
Burn
Cut
Emotional/ Psychological
Dislocation
Fracture
Foreign Body
Other
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