Page 12 - Construction Forms

FORM OF REGISTER OR NOTIFICATION OF TM
CIRCUMSTANCES OF ACCIDENT OR SERIOUS HARM

Required for section 25(1), (1A), (1B), & (3)(b) of the Health & Safety in Employment Act 1992. For
non-injury accident, complete questions 1, 2, 3, 9, 10, 11, 14 & 15 as applicable.

1. Particulars of employer, self-employed person or 7. Period of employment of injured person:
principal: (employees only)
(business name, postal address & telephone number)

1st week 1st month 1-6 months
6 months-1 year 1-5 years Over 5 years
non-employee

2. The person reporting is: 8. Treatment of injury: First aid only
None Hospitalisation
an employer a principal a self-employed person Doctor but no hospitalisation

3. Location of place of work: 9. Time & date of accident/serious harm:
(shop, shed, unit nos., floor, building, street nos. & names, Time: (am/pm)
locality/suburb, or details of vehicle, ship or aircraft) Date: DD / MM / YEAR

Shift: Day Afternoon Night

4. Personal data of injured person: Hours worked since arrival at work:
Name: (employees & self-employed persons only)

10. Mechanism of accident/ serious harm:

Residential address: fall, trip or slip heat, radiation or energy

hitting objects with part of the body

bodybiological factors sound or pressure

chemicals or other substances mental stress

being hit by moving objects body stressing

Date of birth: DD / MM / YEAR Sex: (M/F) 11. Agency of accident/ serious harm:
machinery or (mainly) fixed plant
5. Occupation or job title of injured person:
(employees & self-employed persons only)

mobile plant or transport

6. The injured person is: powered equipment, tool, or appliance
non-powered handtool, appliance, or equipment
an employee a contractor (self-employed person) chemical or chemical product
self other material or substance

environmental exposure (eg. dust, gas)

animal, human or biological agency
(other than bacteria or virus)

WORKSAFE NEW ZEALAND bacteria or virus

Email: seriousharm.notification@worksafe.govt.nz Fax: 09 984 4115

Phone: 0800 030 040 Post: PO Box 165, Wellington, 6140