Operational Management System · Tauranga, Bay of Plenty NZ
4B.FRM.005
Version 1.0
Safety Form
Incident & Near Miss Report
Complete immediately after any injury, near miss, or hazard. Supervisor must review same day. Notifiable events → call WorkSafe NZ immediately: 0800 030 040. | Basis: HSWA 2015 ss 36–56, 109–116; WorkSafe NZ Notifiable Event guidance.
⚠ WorkSafe NZ Notifiable Event? — Check before anything else
Call WorkSafe immediately on 0800 030 040 if any of the following apply. Do NOT disturb the scene (unless needed for safety).
Death or serious injury requiring immediate in-patient treatment
Amputation, loss of consciousness, serious head/spinal injury
Serious burn requiring in-patient treatment
Loss of vision (temporary or permanent)
Hospitalisation for 24+ hours
Serious illness — exposure to agrichemical, substance, or pathogen
Machinery or plant incident causing serious injury/near miss
Fall from height causing serious injury or near miss
1 — Type of Event
2 — Who, When, and Where
3 — What Happened — Full Description
4 — Severity Rating
Rate the actual or potential severity — for near misses, rate the worst case if it had occurred.
1
MINOR
First aid, no lost time
2
MODERATE
Medical treatment, some lost time
3
SERIOUS
Hospitalisation, significant lost time
4
CRITICAL
Notifiable event, life-altering
5
FATAL
Death
5 — Root Cause Investigation (5-Why Method)
HSWA 2015 s36: As a PCBU, 4 Brothers must identify and manage hazards. Answer each "Why?" until the root cause is found — usually 4–5 layers down from the surface event.
Why 1
Why 2
Why 3
Why 4
Why 5
6 — Corrective Actions and Controls
HSWA 2015 s30: Controls must be applied in this hierarchy: eliminate → substitute → isolate → engineer → admin → PPE. Corrective actions must be assigned, dated, and closed out.