CBNZ Incident Report Form

Accident / Incident Report
Date of Report

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reported By

First NameLast Name
Your Position
1. Incident/Accident Information
Date of Incident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of incident
Location of Incident

Other
Accident / Incident Type

Other
2. Incident/Accident Information
Name of persons involved in the incident (Name & Contact Details)
Insert Names
Roles
e.g., Youth Participant, Staff, Visitor, etc.
Contact Information
3. Incident/Accident Description
Detailed Description of the Incident/Accident: (sequence of events that led to the incident, what happened? Use objective, fact-based language)
Provide a factual, step-by-step account of what happened, focusing onthe circumstances leading up to the incident, the incident itself, and any immediate aftermath
Witnessesname and contact details:
If Applicable
4.Injuries (if applicable)
Nature of Injuries:
Describe any injuries sustained, including their severity and location on the bodyable
First Aid/Medical Treatment Provided:
Detail any first aid given, medical treatment,or emergency services involved
5. Response and Actions Taken
Immediate Actions Taken: (what actions were taken by staff or others to address the incident?)
Describe what was done in response to the incident, including staffintervention, evacuation, or securing the area
Follow-up Actions Required:
Describe any ongoing monitoring, communicationwith family members, or further medical attention.
6. Reporting and Notifications
Notifcation (who was notified about the incident? Please also note method in which the notification was given ie In person / Phone call / Email / TXT )
Please include the time the notification was given.
Annexures supporting this report (Eg photographs, statements, witness reports, risk assessments, SWMS, etc.)

Browse Files

Cancelof
Other Notification

Other
7. Preventative Measures
Recommendations to Prevent Future Incidents/Accidents:
Provide any suggestions for improving safety orreducing risks in the future, such as new procedures or additional training.
Thank you for completing this form. It will go to one of the CBNZ managers for further action where required. Please feel free to reach out directly to your manager if you require an immediate response.
Should be Empty:

Accident / Incident Report

1. Incident/Accident Information

2. Incident/Accident Information

3. Incident/Accident Description

4.Injuries (if applicable)

5. Response and Actions Taken

6. Reporting and Notifications

7. Preventative Measures