Incident & Accident Investigation Form
This form must be completed after an incident or an accident occurs involving Auckland Evangelical Church Trust workers, volunteers, or visitors at relevant events or sites
1. Particulars of Accident
Date of Accident
MM
/
DD
/
YYYY
Time of Accident
Time
:
Location
Your answer
2. The injured Person
Name
Your answer
Address
Your answer
Date of Birth
MM
/
DD
/
YYYY
Phone Number
Your answer
Length of Employment
Your answer
Type of Injury
Comments
Your answer
3. Damaged Property
Property or material damaged
Your answer
Nature of damage
Your answer
Object/substance causing damage
4. The Accident
Description of what happened
Your answer
What caused the accident?
Your answer
How serious could it have been?
Minor
Serious
How often is this likely to happen again?
Never
Often
What action has or will be taken to stop another accident like this happening? (Action, By Whom, When)
Your answer
5. Treatment and Investigation of Accident
Type of treatment given
Your answer
Name of person giving first aid
Your answer
Doctor/Hospital
Your answer
Submit
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