Incident Reporting Form

Date of incident:
Time of incident:
Address of incident:
Type of incident:

Customer name (if applicable):
TM Number (if applicable):

Was this reported to any other agency? (E.g. WorksafeNZ, ACC, Workbridge, Resthome etc.)YesNo
If yes, which agency?

Full description of the incident:

Report Submitted by:
Your email:
Your phone:

When an incident happens:

  1. Keep people safe

    Follow our internal incident management process to keep everyone safe. Report serious threats to the police immediately.

  2. Take action if there is an immediate risk to us, our staff or our clients

    You will be aware if the Health and Safety requirements. Act responsibly.

  3. Contact WorkSafe if it is a notifiable event

    If the incident is a notifiable event, you’ll need to keep the site of the event clear and report it to WorkSafe. Follow WorkSafe’s instructions about what to do.

  4. Complete this online form

    Even if you’ve called, you need to report incidents to us in writing using this online form.

Your obligations

We all play a part in protecting the health and safety of ourselves and others in the workplace. We’ll use your report to identify areas where we can work together to improve health and safety. This helps to:

  • improve the way we deliver our services
  • make sure you have the information you need to help keep yourself and others safe.
  • meet your obligations under the Health and Safety at Work Act 2015 you need to work with us to manage health and safety risks.