FARM INCIDENT/NEAR-MISS REPORT
In case of an emergency:
Contact emergency services: 111
Call WorkSafe: 0800 030 040
Date of issue:
WSNZ_2072_APR 16
Employment details
FARM NAME: JOB TITLE:
Permanent Casual
Contractor
Visitor
Accident details
DATE:
Near-miss No treatment
First aid
Doctor
Hospital
Serious harm
TIME:
AM PM
Hours at work: Date reported:
Personal details
NAME:
PHONE NUMBER:
ADDRESS: DATE OF BIRTH:
SEX:
Male
Female
Nature of injury
Strain/sprain Cut Head injury Fracture/break Gradual process
Bruising Burns Poison/chemical Multiple injuries No injury
LOCATION OF INJURY (CIRCLE LOCATION) WHERE DID THE ACCIDENT HAPPEN? (EG SHED, PADDOCK ETC)
HOW DID THE ACCIDENT HAPPEN?
WAS THE PERSON TRAINED FOR THE TASK THEY WERE DOING?
Yes
No
IF A VEHICLE WAS INVOLVED, RECORD TYPE OF VEHICLE
WAS A SIGNIFICANT RISK INVOLVED?
Yes
No
IF YES, WHAT WAS THE SIGNIFICANT RISK?
IS THE RISK ON THE RISK REGISTER?
Yes
No
Back
L R R L
Front
SPECIFIC ACTIONS REQUIRED PERSON RESPONSIBLE BY WHEN DATE COMPLETED
INITIAL NEEDS ASSESSMENT (ONLY COMPLETE IF A DOCTOR’S VISIT WAS REQUIRED)
Able to continue full duties Able to do light duties Unable to work
Help available at home Assistance required at home Transport assistance needed
Form completed by
NAME: POSITION:
SIGNED: DATE FORM WAS COMPLETED:
WHAT HARM COULD HAVE HAPPENED?
STEPS TAKEN TO PREVENT A SIMILAR EVENT HAPPENING AGAIN
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