DBNZ Incident Investigation

Reported By

Name *

Phone *

Email Address *

Relation to DBNZ *OwnerEmployeeContractorVisitor

Health and Safety Representative Phone *

Health and Safety Representative Email Address *

The Injured Person

Is there an injured person? *YesNoIf the answer is Yes, pleae complete all the fields in this section

Name

Phone

Street Address

City

State/Province

DOB

Length of Employment

RoleOwnerEmployeeContractorVisitor

Was a Drug and/or Alcohol Test performed?YesNo

Result

Witnesses

Are there any witnesses? *YesNoIf the answer is Yes, pleae complete all the fields in this section

Name

Phone

Name

Phone

The Incident

Describe what happened (attach sketch or photos as required)

Date

Time:

Reported To:

Place and exact location:

Working conditions at the location and time of the incident

Weather conditions at the time of the incident

Describe the details in the order of what happened (immediately before, during, and after the incident):

Provide photo taken immediately after incident and/or items directly related to the incident

IDENTIFY IMMEDIATE CAUSE(S)

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?

Plant, Equipment and SubstancesWas 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?

ProceduresWas 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?

PeopleDid anyone do anything that contributed to the incident? If so, why did they do it and what needs to be done to correct this?

Hazard IdentificationWas/were hazard(s) previously identified? If not, why not? What needs to be done to manage this hazard?

Hazard ControlWere 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?

Other hazards associated with this incidentDescribe 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?

Hazard ManagementDid 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?

Health and Safety Standards usedWas the correct PPE being used? Describe any best practice or industry standards that are used in your workplace to help manage hazards. Where were they relevant to this incident?

SupervisionWas there adequate supervision at the time of the incident? If not, why not? What needs to be done to ensure appropriate and effective supervision?

TrainingWas training or instruction in using the equipment, plant, or substance sufficient and effective? If not, why not? What can be done to improve training and/or instructions?

CompetenceDid 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?

ReviewIs this a repeat of a previous incident? Were corrective actions implemented when there was an incident or when a concern was raised in the past? If not, why not? What needs to be done to implement corrective actions?

GovernanceWas their sufficient oversight by senior managers and/or directors of the hazards and risks that contributed to this incident? What system for receiving information about key hazards and risks do the senior managers/directors have in place?

Other causesIf appropriate, advise what other cause(s) contributed to the incident

Nature of Injury

What part of the body is affected and how

Are there any injuries? *YesNoIf the answer is Yes, pleae complete all the fields in this section

Type of injury/illness

Body Part injured

Treatment

Is treatment or was treatment required? *YesNoIf the answer is Yes, pleae complete all the fields in this section

A&E/Hospital

Doctor

Type of treatment provided

Prevention

What immediate action has been taken to prevent a reoccurrence (e.g. Lockout, barricades?)

Who:

When:

Have all preventative actions been reviewed by management and completedYesNo

Manager Sign

Date Completed

Notification and Investigation

WORKSAFE PHONE: 0800 030 040 (24 hours)

Was the incident notified? *YesNoIf 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:

Notes

Incident Investigation Closure

Is the Investigation Closed? *YesNoIf the answer is Yes, pleae complete all the fields in this section

This incident investigation can only be closed by an officer or PCBU after ensuring they have conducted the appropriate due diligence and are satisfied that the corrective actions have been fully implemented.

Signed

Text

Date

Full Name

Position