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Incident/Injury Form
Date/Time Occurred *
Location *
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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
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Event (What happened during the event?) *
Post-Event (What happened after the event?) *
Affected Persons Name
Persons Status
Employee
Temp
Visitor
Other
Other
Medical Treatment
Doctor, hospital, physio?
Lost Time?
First Aid?
Lodged ACC Claim? *
Yes
No
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Mark Injury
Body part injured?
What type of injury
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Clear Area
Body part injured?
Head
Wrist
Neck
Hand
Shoulder
Leg
Torso
Knee
Arm
Ankle
Elbow
Foot
Other
What type of injury
Bruising
Electric Shock
Burn
Fracture
Cut
Foreign Body
Dislocation
Heart Attack
DPI
Inflammation
Sprain/Strain
Internal
Other
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