Incident & Accident Investigation Form
This form must be completed after an incident, near miss, or an accident occurs involving Auckland Evangelical Church Trust workers, volunteers, or visitors at relevant events or sites
1. Particulars of Incident
Date of Incident
Time of Incident
Type of Incident
Accident: Any unexpected, unplanned or undesired event or circumstance that has a negative implication; it results in harm to people, loss of life (notifiable events), or damage to property.
Near Miss: An unexpected and unplanned event or series of events that did not result in injury, illness, or damage to property, equipment, materials or the environment – but had the potential to do so under slightly different circumstances. Only a fortunate break in the chain of events prevented an injury, fatality or damage.
Incident: An event or series of events that has taken place or occurred which may or may not have resulted in a near miss or accident.
(Notice that all accidents are incidents, and all near misses are incidents, but not all incidents result in near misses or accidents.)
Was this an Incident, Near Miss, or an Accident?
2. The injured Person
Date of Birth
Length of Employment
Type of Injury
3. Damaged Property
Property or material damaged
Nature of damage
Object/substance causing damage
4. The Accident
Description of what happened
What caused the incident?
Hazard Impact Scale
How serious could it have been? (IMPACT)
How often is this likely to happen again? (LIKELIHOOD)
Priority (Likelihood x Impact)
0 - 1 (Very Low)
2 - 3 (Low)
4 - 9 (Medium)
10 - 16 (High)
17 - 25 (Very High)
What action has or will be taken to stop another incident like this happening? (Action, By Whom, When)
5. Treatment and Investigation of Incident
Type of treatment given
Name of person giving first aid
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This form was created inside of Auckland Ev Church.