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Incident/Hazard Report Form
Incident/Hazard Report Form
Wilson Contractor / Member of Public – Incident and Hazard report form
Incident Type
-- Select an option --
Injury/Illness
Hazard
Property Damage
Person Type
-- Select an option --
Contractor
Member of the public
Full name
Full name
Contact email
Mechanism of Incident
-- Select an option --
Acts of violence
Animal bites / stings
Being hit by moving objects
Biological factors
Caught between objects (crush)
Chemical or substance
Contact with electricity
Contact or exposure to heat and cold
Hitting objects with a part of the body
Mental stress factors
Muscular stress while handling, lifting, carrying, putting down objects or repetitive movement
Muscular stress with no objects being handled
Exposure to noise (sharp, sudden, or long term exposure)
Slips, trips and falls (including from same level and from height)
Vehicle incident
Description
Country
-- Select an option --
Australia
New Zealand
State
-- Select an option --
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Regions
-- Select an option --
Ashburton
Auckland
Blenheim
Christchurch
Dargaville
Dunedin
Far North
Greymouth
Hamilton
Hastings
Hawkes Bay
Hutt Valley
Invercargill
Kaikohe
Napier
Nelson
New Plymouth
Oomaru
Palmerston North
Papakura
Paraparaumu
Pukekohe
Queenstown
Rotorua
Tauranga
Timaru
Wanganui
Wellington
Whangarei
Incident location (must include state)
Occurred date
Occurred time
Injury/illness description
Body Part Injured
-- Select options --
Abdomen
Ankle
Arm
Back
Chest
Ear
Elbow
Eye
Face
Finger
Foot
Groin
Hand
Head
Hip
Internal
Knee
Leg
Neck
Shoulder
Skin
Toe
Wrist
Initial Treatment Taken
-- Select options --
No treatment
On-Site First Aid Officer
Ambulance/Paramedic
Off-Site Medical Clinic
Hospitalisation
Resolved
-- Select an option --
Yes
No
Action taken
-- Select an option --
Removed
Reduced
Action details
Image upload
Submit
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