Incident notification form

Use this form to report any Accident, Injury, Incident or Illness

that occurred on AUT
University premises or whilst on duty for AUT offsite.
Person affected (or their manager):
1. Immediately: Please ensure that any serious harm incidents or incidents
where there was potential for serious harm are reported immediately by phone
to your Health & Safety Advisor so appropriate investigations can be
completed for Worksafe NZ.
2. Within 24 hours of incident - please download and fill in the Section A and
then scan and send to cmcdowel@aut.ac.nz (Health and Safety admin).
3. Within 2 weeks after the incident - Fill in Section B and return whole form
to cmcdowel@aut.ac.nz (Health and Safety admin).
4. Keep copies of this form with the Faculty/Division & the employee.

Section A
Name:

Date of birth:

Sex:

Position:

Faculty/Division/Contractor:

Contact phone:

Email:

Manager/Supervisor /Lecturer (in case of a student or contractor) contact phone and email:

Date of event:

Time of event:

Place of event :

Room:

Building Campus/Site:

Activity at time of event:

Description of event that lead to injury/incident/illness/accident

Who was involved/injured, what was going on (activity/job), what went wrong, what were the
consequences (what was the extent of the injury/damage)
Signature of person(s) involved:

Incident notification form

Use this form to report any Accident, Injury, Incident or Illness
that occurred on AUT
University premises or whilst on duty for AUT offsite.

Section B
Medical treatment obtained? (circle one)
Nil
First Aid
AUT Health & Counselling
Doctor
admitted
Other

Hospital casualty (A& E)

Hospital

Outcome for injured person Time lost from work? ____ days _____ hours. ____ Not yet returned
to work.
Details of witness (name, phone and email)

Incident notification form

Use this form to report any Accident, Injury, Incident or Illness
that occurred on AUT
University premises or whilst on duty for AUT offsite.
For person injured to fill out:
If slip, trip or fall involved, provide additional detail:
Slip/fall along the ground
Slip/fall on stairs

Slip/fall on sloping surface

Condition of walking surface

Type & condition of footwear

Fall from a height?

What was being done at time of incident:

If needle or sharps injury/incident

Was the needle or sharp sterile?
YES

NO (Circle one)

Has the person been subsequently tested for HIV, Hepatitis B and Hepatitis C?
YES NO (Circle
one)
If YES, date when this occurred ___ / ____/_____ by whom________________ Dr / Medical Centre
(Circle one)

For supervisor to fill out

Information about personal protective equipment
Should personal protective equipment have been worn during the task being undertaken at the
time of the incident?
Was it being worn/used?

Type of personal protective equipment

required:

Was it available?

Corrective action recommended by supervisor & action taken (date each)

Changes to work environment:
Changes to work practices/job design

Modifications or repairs to machinery,

equipment or tools:
Personal protective equipment (additional or
changes)

Additional Training:
Signature name and date of supervisor:
Signature name and date of Head of School or Section:
Comment on difficulties in implementing the corrective action recommended above & additional
resources or assistance required to implement them:

Health, Safety and Wellbeing use:

Investigating Authorities Notified? Worksafe NZ, Maritime NZ, Energy Safety, NZ Police,,MoH,
Other___________