Event Report
Human Resources
EMPL ID
Note: Your Employee ID is on your Canterbury Card (top right of barcode)
(HR Only)
Note: If this report is in relation to serious harm please contact UC Health & Safety Advisor immediately
on ext 6630 health-safety@canterbury.ac.nz.
To be completed in consultation with your manager or supervisor and returned to Health and Safety within
24 hours of event.
Type of event:
Where did the event occur (building, floor, dept, school etc)
Injury
Illness
Discomfort & Pain
Near Miss
Incident
Serious Harm (contact Health
(OOS/RSI etc)
and Safety immediately)
Event relates to:
Employee
Post-Grad Student
Under-Grad Stdnt
Visitor
Contractor
Volunteer
Date & time of Event:
Person on Work Experience
Date & time reported to
Manager:
Employee ID No.:
Treatment of illness/injury:
Details of person involved in the event:
None
Address:
Doctor
Physiotherapist
Nature of injury/illness:
Phone:
Date of Birth:
Sex:
Boxes 1-5 to only to be completed by employees,
contractors, and people on work experience:
1
First aid
Hospitalisation (only if admitted, otherwise Doctor)
Name:
Where person normally works (Department/
School/Service/Contractor):
2
Occupation of person involved:
3
Period of
employment
1st week
7 -12 mnths
1st month
1-5 yrs
1-6 months
Over 5 yrs
4
Shift:
Day
Afternoon
Night
5
Hours worked from arrival at work till incident:
Fatal
Head injury
Amputation, incl. eye
Internal injury or trunk
Burns
Multiple injuries
Bruising or crushing
Nerves or spinal cord
Damage to artificial aid
Open wound
Disease (specify below)
Poisoning or toxic effects
Dislocation
Psychological disorder
Electrocution
Puncture wound
Foreign body
Sprain or strain
Fracture
Tumour
Noise induced hearing loss
Vision impairment
Other (please specify)
Source of injury/illness:
Animal
Machinery
Bacteria or virus
Motor vehicle
Chemical/chemical prducts
Non powered hand tool
appliance or equipment
Environmental agencies
Floor
Human
Other
Human Resources – hs_frm01
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Powered hand tool
appliance or equipment
Wall
Date issued: 11-Nov-15
Accident type:
Body part:
Biological factors
Inhalation
Abdomen
Lower leg
Body stressing
Moving object/debris
Ankle
Mouth
Chemical/chem. substance
Pressure
Back
Neck / back of head
Environmental factors
Psychological stress
Chest
Nose
Fall, trip or slip
Sound
Ear
Pelvis
Other
Stationary object
Elbow
Shoulder
Heat/radiation/electricity
Eye
Skin (specify body part)
Face
Spine
Finger
Thumb
Foot
Toe
Hand
Trunk
Head (except face)
Upper arm
Hip
Upper leg
Internal organs (systemic)
Wrist
Knee
No injury/illness
Lower arm
Unknown
Details of person witness to the event (if applicable):
Name:
Phone:
Signature of person involved in event:
Date:
______ / ______ / __________
Event Investigation Report
Describe in detail what happened (how, where, what, why): Include any comments on what
contributed to the event, eg. lack of training, workplace design, unsafe work methods, safety rules not followed etc)
Describe what action will be taken to prevent a possible recurrence of this type of event (eg. requisition
sent to maintenance, further training provided to staff etc):
Action
Responsibility of
Date for
completion
(Name and Employee ID)
Did this investigation identify any new, uncontrolled hazards?:
Yes
No
If yes, describe (NB: Ensure ‘Identify and Manage a Hazard’ process is initiated and/or documentation is updated):
Authorisation
I confirm that I have reviewed this report and that any required actions will be taken in response to this event.
Name of Manager/Head:
Employee ID:
Signature: (Manager/Head)
Date:
HRPF: Event
Human Resources – hs_frm01
Page 2 of 2
Date issued: 11-Nov-15