Dunedin Housing Maintenance Contractors Ltd

Accident / Incident Reporting & Investigation Form


Company Name: ______

Details of Accident
Date of accident
M T W T F S S / Time / Location / Date reported
Details of Injured Person
Name / Address
DOB / Gender M/F
Date of accident / Occupation
Accident Description
Description: Describe what happened (space overleaf for diagram ¾ essential for all vehicle accidents)
Type of Injury/Illness
Circle all that are relevant /  Amputation
 Bruising
 Burn or scald
 Chemical reaction
 Dislocation
 Foreign body
 Fracture
 Internal
 Laceration/cut
 Scratch/abrasion
 Strain/sprain
 No injury
 Other (specify)
R or L or Both Sides
Treatment of Injured Personnel
Type of treatment given /  None required  First Aid  Doctor/Hospital
Name of person giving first aid / Details of first aid given
Referral to Doctor/Hospital? / Was a first aid kit on site Yes / No
 Lost Time  Damage  Medical Treatment Injury  First Aid Injury  Near Miss
Analysis
What were the causes of the accident?
Location - Was there anything at/in the location that caused the incident? If so, why was it there and what needs to be done to address this?
People - Did anyone do anything that contributed to the incident? If so, why did they do it and what needs to be done to correct this?
Plant, Equipment, Substances – was there anything dangerous about the plant, equipment and/or substances that were used? If so, why was it unsafe and what needs to be done to make it safe e.g. (electrical equipment current quarterly testing & tagging)?
Procedures – was there anything about the procedures, including those for emergencies that caused the incident? If so, what was it and what needs to be done to correct this?
Hazard Management
1.  Was/were hazard(s) previously identified? If not, why not? What needs to be done to manage this hazard?
2.  Were there enough checks done to ensure the safe use of the premises, plant, substances and procedures? If not, why not, What needs to be done to ensure premises, plant, substances, and procedures create a safe work environment?
3.  Describe how you currently control hazards associated with this incident? If they failed, why did these controls fail? What needs to be done to control this hazard?
4.  Did any of the hazard management systems designed to eliminate, isolate or minimise the risk fail? If so, why and what can be done to prevent this from happening again?
Training & Competencies
1.  Was training or instruction in using equipment, plant or substance sufficient and effective? If not why not? What can be done to improve training and/or instructions?
2.  Did staff have the right qualification and/or experience to use the tools and procedures for the task they were doing? If not, why not? What can be done to improve competence in using the tools and procedures?
H&S Standards – Describe any best practice or industry standards that are used in your workplace to help manage hazards. Where were they relevant to this incident?
Supervision – Was there adequate supervision at the time of the incident? If not, why not? What needs to be done to ensure appropriate and effective supervision?
How bad could it have been? / What is the chance of it happening again?
 Very serious /  Serious /  Minor /  Minor /  Occasional /  Rare
Prevention
What action has or will be taken to prevent a recurrence?
Use space overleaf if required / By whom / By When / Tick
when
actioned

Damaged Property

Property/ material damaged
Nature of damage
Object/substance inflicting damage:

Investigation and Reporting Details

Accident investigated by:
Serious Harm? / Yes / No / Reasons:
Work Safe NZ notified? / Yes / No
Date: / Comments / Contact name / number provided:
Police Department notified? / Yes / No
Date: / Comments / Contact name / number provided:
Regional Council notified? / Yes / No
Date: / Comments / Contact name / number provided:
Client notified? / Yes / No
Date: / Comments / Contact name / number provided:

Investigator Signature ______Date: ______

Employee Signature ______Date: ______

Supervisor Signature ______Date: ______

VEHCILE INCIDENT ONLY
Name / Address
Age / Phone number
Date of accident / D.Licence Details (take photo) No:
Insurance Details: Insured Yes / No Company Name:
Owner of the vehicle: Yes / No Make & Model: (take photo include registration)
Damaged to DHMC Property / Damage to Other
Property/ material damaged
Nature of damage
Object/substance inflicting damage:
Include diagram (essential for all vehicle incidents)

Hard copies of forms are available at DHMC office, foreman and electronic electronic version.

Dunedin Housing Maintenance Contractors Ltd - Accident Investigation Form

Document No: HS22.2 - Date updated: 17/05/2016

R:\DHMC Health and Safety\DHMC H&S Policies & Procedures\ACCIDENT AND INCIDENT 22\22.2 Accident Incident Reporting & Investigation Form Rev2.doc