Health & Safety Incident Report

Health & Safety Incident/Near-miss Report

Recording incidents/accidents and near misses helps us be a safer church
This form is based on WorkSafe NZ's Incident/Near-miss report template and is designed to ensure it meets legislative requirements.

All personally identifiable information will be held in accordance with the WMCANZ and local church/trust Privacy Policies.

Saving and continuing the form later. You can save the form by clicking on the save button at the end of any page (click on the "Skip Create an Account link at the bottom of the save dialog" that appears and follow the prompts). You can then use the link that is sent to your email to come back and complete the form from where you left off.

Any problems please contact the Director of Operations (dirops@wesleyan.nz)
Your Details
Name of Church / Trust*
Your Name*

First NameLast Name
Your Role / Position
Your email address*

Confirmation Emailexample@example.com
Your Phone Number*

Area CodePhone Number
Today's date*

DayMonthYear

Details of the person injured or involved in the near miss (where known)
Their name

First NameLast Name
Their date of birth

DayMonthYear
Their gender
Their phone number

Area CodePhone Number
Their email

Confirmation Emailexample@example.com
Their Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How are they involved in/with the church or trust (select all that apply)*

LeaderEmployeeVolunteerAttender / memberGuestOther

Health & Safety Incident/Near-miss Report