Health & Safety Incident Report Form
Swimming NZ
Particulars of Incident
Date
-
Day
-
Month
Year
Time
Location
What environment did this occur in?
Please Select
Training
Event
Camp
Meeting
Function
Other
Who was hosting?
Please Select
Swimming NZ
Region
Club
Reported By
Name
First Name
Last Name
Contact Email
example@example.com
Contact Number
Please enter a valid phone number.
The Injured Person
Name
First Name
Last Name
Occupation
Please Select
Swimmer
Coach
Team Manager
Official
Staff
Volunteer
Spectator
Club
Contact Email
example@example.com
Contact Number
Please enter a valid phone number.
Was a drug and/or alcohol test performed?
Please Select
Yes
No
If yes, what was the result?
Witness
Name
First Name
Last Name
Contact Email
Contact Number
The Incident
Type of Incident
Incident
Injury
Illness
Complaint
Environmental
Notifiable Event
Describe what happened?
Nature of the injury - what part of the body is affected and how?
Property damage - what damage was caused and how?
Analysis - what do you think caused or contributed to the incident?
Prevention - what action has been or could be taken to prevent a re-occurence?
Treatment
If required, what type of treatment was provided and who by? (eg: A&E, doctor, first aid, etc)
Notification & Investigation
If the incident is a notifiable event, an Incident Investigation must be completed and submitted to WorkSafe. WorkSafe phone: 0800 030 040
Has WorkSafe been notified?
Please Select
Yes
No
If so, please provide details as to who has contacted and when.
Other
Is there any other information required for this report?
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