Page 13 - Construction Forms

12. Body part: 14. Where & how did the accident/serious harm happen?
(If not enough room attach separate sheet or sheets.)
head neck trunk upper limb lower limb
multiple locations systemic internal organs 15. If notification is from an employer:
13. Nature of injury or disease:
(specify all) (a) Has an investigation been carried out? yes no

fatal (b) Was a significant hazard involved? yes no
fracture of spine Signature:
other fracture
dislocation Date: DD / MM / YEAR
sprain or strain
head injury Name:
internal injury of trunk (capitals)
amputation, including eye
open wound Position:
superficial injury (capitals)
bruising or crushing
foreign body
burns
nerves or spinal chord
puncture wound
poisoning or toxic effects
multiple injuries
damage to artificial aid
disease, nervous system
disease, musculoskeletal system
disease, skin
disease, digestive system
disease, infectious or parasitic
disease, respiratory system
disease, circulatory system
tumour (malignant or benign)
mental disorder

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

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