The Critical Incident Report Form is a fundamental document required under New Zealand health and safety legislation, particularly the Health and Safety at Work Act 2015. It is designed to be used whenever a significant incident, accident, or near-miss occurs in the workplace. The form must be completed as soon as practicable after an incident, capturing crucial details while they are fresh and ensuring proper notification to relevant authorities when required. It serves multiple purposes: documenting the incident for legal compliance, facilitating internal investigation and response, identifying preventive measures, and supporting insurance or compensation claims if necessary. The document includes sections for immediate response actions, witness statements, and follow-up recommendations, making it an essential tool for risk management and continuous improvement in workplace safety.
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1. Incident Identifier: Unique reference number, date, time, and location of the incident
2. Reporter Details: Name, role, and contact information of the person completing the report
3. Incident Classification: Type and severity of incident, including whether it's a notifiable incident under the Health and Safety at Work Act 2015
4. Incident Description: Detailed account of what happened, including sequence of events
5. Persons Involved: Details of all people involved, including witnesses, affected parties, and their roles
6. Immediate Actions Taken: Steps taken immediately following the incident to ensure safety and contain the situation
7. Notifications Made: List of parties notified (e.g., emergency services, WorkSafe NZ, management)
8. Initial Risk Assessment: Assessment of immediate risks and hazards identified
9. Contributing Factors: Analysis of factors that may have contributed to the incident
10. Recommendations: Immediate and long-term actions recommended to prevent recurrence
1. Environmental Impact: Required when incident involves environmental damage or contamination
2. Equipment/Property Damage: To be included when physical assets are damaged during the incident
3. Media/Communications: Required for high-profile incidents requiring public communications
4. Cost Impact: Optional section for documenting financial implications of the incident
5. Business Continuity Measures: Required when incident affects business operations
6. Third Party Involvement: To be included when contractors or external parties are involved
7. Regulatory Compliance: Required for incidents involving regulatory breaches or compliance issues
1. Appendix A: Witness Statements: Template and collected statements from witnesses
2. Appendix B: Photographic Evidence: Photos, diagrams, or visual documentation of the incident
3. Appendix C: Risk Assessment Matrix: Standard risk assessment tool for evaluating incident severity
4. Appendix D: Notification Checklist: Checklist of required notifications based on incident type
5. Appendix E: Investigation Guidelines: Procedures for conducting thorough incident investigations
6. Appendix F: Related Documents: Relevant procedures, permits, or certificates related to the incident
7. Appendix G: Follow-up Action Plan: Template for documenting and tracking corrective actions
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