Hazard Form - Woodhillforest.co.nz

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Hazard FormMalcolm2018-06-06T11:36:03+12:00

All accidents or incidents (including ‘near miss’)that occur in Woodhill forest, must be reported to the permit provider. If you are not involved directly in the incident but have witnessed unusual sites or behaviour and / or possible future hazards whilst exersising your permit, you and/or your company are required to report those incidents / accidents to the permit provider.
Person reporting incident / accident:
Name*
Date
Address
Incident Type (Threat)
- Assault
- Caught in/under/between
- Confined space
- Cut/puncture/scrape
- Electrical
- Falls from height
- Strain
- Pressure release
- Slips & trips
- Struck by
- Water related
- Other - provide details below
Provide details of the incident
Company*
Email Address*
Phone Number
Mobile
Work Contact Number
Date of Incident
MM slash DD slash YYYY
Time of Incident

: Hours

Minutes

AM/PM
Potential Severity
Details of incident:
Location of Accident / incident
Number of people affected
Details of Accident / Incident
Immediate Causes (people, equipment, materials, environment?)
Underlying Causes
Action Plan(s) to Rectify
Person responsible
Due Date
MM slash DD slash YYYY
Who is responsible for completion?
Name
Date
MM slash DD slash YYYY
Actions confirmed as completed
Name
Completion Date
MM slash DD slash YYYY