Accident / Near Miss Reporting Form

Accident / Near Miss Reporting Forms
Please select that which applies to you:*

Accident FormNear Miss Form
Accident Reporting Form

Please Note: All reportable incidents must be reported. All reported incidents are: used for trend analysis, future planning and reporting to the appropriate authorities as required. kept on file in the CYC Waihola office. It is preferable that this form is completed within 24 hours of the incident occurring. All incidents on the Incident Severity Table that are level 3 and above will be reported on the National Incident Database (NID) and incidents level 6 and above are reported to Worksafe as well. The contents of form will be kept confidential to CYC Waihola management. Only summarized details will be given discerningly by the Operations Manager to caregivers and outside agencies if requested
Date of Incident *

MonthDayYear
Date
Time of Incident*
Camp / Group Name*
Name of Person Completing form*
Role of Person Completing form*
Key Person

The key person is generally the main victim in the accident. You can list others (or other key people) later.
Key Person's Name:*
Key Person's Age:*
Key Person's Gender*

MaleFemale
Nature of Injuries:*
Please specify types of injuries sustained if any
Incident Details
Location of Accident:*
Accident Category:*
Other People Involved:

Please provide names of all other people involved.
- List anyone else that could have been harmed
- List what the supervision present was and note any qualifications if applicable
- Note the numbers of participants in the activity
Others involved:*
Accident Summary:

Provide detail following:
- what led to incident
- what actually happened
- key things that were said or done prior or during the incident
- note any damage to property
- note any other important facts
Accident Summary:*
What caused the accident in your opinion?*
Please provide your opinion as to why the accident occurred
Environmental Conditions
Precipitation:*

IndoorsClear SkiesOvercastFogDrizzleLight RainHeavy RainSnow
Temperature*

Less than 0°C0°C - 10°C10°C - 20°C20°C - 30°COver 30°C
Wind:*

IndoorsNo WindBreezesLight WindStrong WindGail
After The Accident

Action Taken

Please provide details of what happened after the incident
- Who took the action
- What were the supervision levels during any action taken
- Note key things that were said
- Note any other important facts
Action Taken:*
Any outside agencies involved:
Any other follow up required:
Please specify here if there was any follow-up treatment needed.
Near Miss Reporting Form
*Please Note
- All reportable incidents must be reported.
- All reported incidents are:
  - used for trend analysis, future planning and reporting to the appropriate authorities as required.
  - kept on file in the CYC Waihola office
- It is preferable that this form is completed within 24 hours of the incident occurring
- All incidents on the Incident Severity Table that are level 3 and above will be reported on the National Incident Database (NID) and incidents level 6 and above are reported to Worksafe as well
- The contents of form will be kept confidential to CYC Waihola management
  - Only summarised details will be given discerningly by the Operations Manager to caregivers and outside agencies if requested
Key Incident Details
Date of Incident*

MonthDayYear
Date
Time of Incident*
Camp / Group Name"*
Name of Person completing form*
Role of Person completing form:*
Key Person

The key person is the person that was key to the near miss occurring (i.e., they would have been the main victim had something gone wrong) You can list others (or other key people) later.
Key Person's Name:*
Key Person's Age:*
Key Person's Gender*

MaleFemale
Location of Incident*
Other People Involved:

Please provide names of all other people involved

list anyone else that could have been harmed (i.e. other key people)
list what the supervision present was and note any qualifications if applicable
note the numbers of participants in the activity
Other people involved:*
Incident Summary:

Provide detail including:
- what led to incident
- what actually happened
- key things that were said or done prior or during the incident
- note any damage to property
- note any other important facts
Incident Summary:*
What caused the incident in your opinion?*
Please provide your opinion as to why the incident occurred.
Environmental Conditions
Precipitation:*

IndoorsClear SkiesOvercastFogDrizzleLight RainHeavy RainSnow
Temperature:*

Less than 0°C0°C - 10°C10°C - 20°C20°C - 30°COver 30°C
Wind:*

IndoorsNo WindBreezesLight WindStrong WindGail
After the Incident:

Action Taken

Please provide details of what happened after the incident
- who took the action
- what were the supervision levels during any action taken
- note key things that were said
- note any other important facts
Action Taken:*
Any outside agencies involved:
Any further follow-up required:
Should be Empty:

Accident / Near Miss Reporting Forms

Accident Reporting Form

Key Person

Incident Details

Environmental Conditions

Near Miss Reporting Form

Key Incident Details

Key Person

Environmental Conditions