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
MM
/
DD
/
YYYY
Time of Incident
Time
:
Location
Your answer
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
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 incident?
Your answer
Hazard Impact Scale
How serious could it have been? (IMPACT) *
Insignificant
Catastrophic
How often is this likely to happen again? (LIKELIHOOD) *
Rare
Almost Certain
Priority (Likelihood x Impact) *
What action has or will be taken to stop another incident like this happening? (Action, By Whom, When)
Your answer
5. Treatment and Investigation of Incident
Type of treatment given
Your answer
Name of person giving first aid
Your answer
Doctor/Hospital
Your answer
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