MINING OPERATION NOTIFIABLE EVENT FORM
Required for Section 56 of the Health and Safety at Work Act 2015 and
Regulation 226 of the Health and Safety at Work (Mining Operations
and Quarrying Operations) Regulations 2016.
1. Particulars of mining operation
Operation details: (include location and type)
Name of operator:
Business address:
Is it a notifiable event under
Schedule 5 of the Regulations 2016? Yes No
If yes, which notifiable accident:
Work phone:
Mobile phone:
Email:
Has an investigation been carried out? Yes No
Yes No
Describe any hazards involved:
Site senior executive
Name:
Business address:
Were any of the hazards principal hazards? Identify the hazards that were principal hazards:
Work phone:
Mobile phone:
Email:
3. Particulars of notifiable event
2. Particulars of notifiable event
Location within mining operation where event occurred:
Where and how did the event occur? (describe events leading
up to the event. If not enough room, attach separate sheet(s) of paper)
Time of event: HH : MM
Date of event: Shift: DD / MM / YEAR
day afternoon WSNZ_2471_May 17
Hours worked since arrival:
WORKSAFE NEW ZEALAND
PO Box 165, Wellington 6140
0800 030 040 www.worksafe.govt.nz [email protected]
night
Describe any plant involved in the event: (include make and model)
Nature of injury or illness: (select one or more of the following)
fatal fracture of spine
fracture other than spine fracture sprain or strain dislocation
head injury
internal injury of trunk open wound
amputation (including eye) superficial injury foreign body Type of injury or illness or fatality: (if any)
burns bruising or crushing
nerves or spinal cord multiple injuries puncture wound
poisoning or toxic effects damage to artificial aid
disease, nervous system disease, musculoskeletal system
disease, digestive system
disease, infectious or parasitic
disease, respiratory system
Name of injured person: (if any)
disease, circulatory system
tumour (malignant or benign)
Was a notifiable event involved? Yes No
4. Additional particulars required in cases of notifiable injury
or illness or fatality (if any)
disease, skin mental disorder
Mechanism of injury or illness or notifiable incident (if fatality):
(select one or more of the following)
Particulars of injured person (if any)
Residential address:
fall, trip or slip sound or pressure
body stressing biological factors
mental stress hitting objects with part of the body
being hit by moving objects bacteria or virus heat, radiation or energy
chemicals or other substances
animal, human, biological agency (other than bacteria or virus)
Date of birth: DD / MM / YEAR
Sex: M F
Agency of injury or illness or notifiable incident (if fatality):
(select one or more of the following)
machinery or (mainly) fixed plant
Occupation or job title:
mobile plant or transport
powered equipment, tool or appliance
Self-employed? Yes No
non-powered handtool, appliance or equipment
chemical or chemical product Employer:
material or substance Period of employment: (employees only)
(select one of the following)
first week environmental exposure (eg dust or gas)
first month 6 months – 1 year 1-6 months
1-5 years animal, human, biological agency (other than bacteria or virus)
over 5 years
Signature:
Particulars of injury (if any)
Treatment: (select one of the following)
none first aid only doctor but not hospitalisation
hospitalisation
Name:
Body part affected: (select one or more of the following)
head neck multiple locations bacteria or virus
trunk lower limb upper limb
systemic internal organs
Position:
Date: DD / MM / YEAR