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DBNZ Incident Record
Overview
Type of Incident
Near Miss
Incident
Serious Harm
Environmental
Other
Reported By
Date
Phone
Email Address
Relation to Business
Owner
Employee
Contractor
Visitor
The Injured Person
Name
Street Address
Apartment, suite, etc
City
Occupation
Age
Phone
Was a Drug and/or Alcohol Test performed?
Yes
No
Result
Length of Employment
Relation to Business
Owner
Employee
Contractor
Visitor
Witness/s
Are there any witnesses?
Yes
No
If the answer is Yes, pleae complete all the fields in this section
Name
Phone
Phone
Name
The Incident
Near Miss
Nature of Injury
Property Damage
Analysis
Prevention
Have all preventative actions been reviewed by management and completed?
Yes
No
If the answer is Yes, pleae complete all the fields in this section
Manager Sign:
Date Completed
Treatment
Is treatment or was treatment required?
Yes
No
If the answer is Yes, pleae complete all the fields in this section
A&E/Hospital
Doctor
Type of treatment provided
Notification and Investigation
Worksafe Phone 0800 030 040 (24 hours)
Was the incident notified?
Yes
No
If the answer is Yes, pleae complete all the fields in this section
WorkSafe advised by
Date
Time
Investigation conducted by
Date
Time
Hazard Register updated by
Date
Time
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