Incident report
Form for reporting Near miss and Harm incidents when riding on a Nextbike share bike OR working for Nextbike New Zealand Limited. Submitting this form will send email notification to company management.
Riders name? *
For some incidents it will be more appropriate to just name the rider source for example: Remuera Primary Yr 5/6, or the piece of equipment that was nearly damaged for example: vehicle. Please include a contact number or email if you'd like us to contact you.
Reporters name? *
This could be the same as "Riders name" in some cases. Please include a contact number or email if you'd like us to contact you.
Date? *
MM
/
DD
/
YYYY
Incident severity? *
The harm descriptors assume the following descriptions: Near Miss - No actual harm or loss. Low - Could be fixed by self or colleague with common sense or basic qualifications, for example first aid. Full recovery expected. Medium - Requires professional and/or qualified help to fix. Full recovery expected. High - Requires professional and/or qualified help to fix. Permanent damage or destruction.
Incident and, if applicable, injury description? *
What was the person or equipment doing in the moments before the incident? Can you describe the location, time of day and the weather conditions? Do you know the Nextbike share bike number?
Treatment description? *
Use NA if incident was a "Near miss"
Staff name who completed this form? *
Include additional names of staff, in brackets, who were working at the location and time of the incident. If completed by member of the public riding a Nextbike share bike use NA
Had the hazard already been identified? *
If you are a member of the public riding a Nextbike share bike use Unsure
Were Eliminate or Minimise suggestions followed? *
If you are a member of the public riding a Nextbike share bike use Unsure
What additional Eliminate or Minimise suggestions could be used?
Hazard register updated? *
If you are a member of the public riding a Nextbike share bike use NA
Copy sent to client? *
If you are a member of the public riding a Nextbike share bike and would like a copy of this Incident report, select Yes, and include your email in the Additional comments question below
Additional comments?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy