Generic forms never ask the notifiable question
A form that captures the event but never asks whether it meets the s25 tests leaves the notification decision to whoever reads it later — often days later, after the site has already been cleared.
Incident & Near-Miss Report Form (NZ)
A single reporting form that captures the event, applies the HSWA 2015 notifiable-event tests, and tells the person filling it in whether WorkSafe has to be notified — before the 5-year record-keeping clock starts.
⚖️Built on HSWA 2015 s25 / s56
👷Reviewed by OH Professionals
✏️Editable .docx
NZD 99
Instant DownloadInstant download · Editable .docx
Most incident forms in circulation are event-capture only — who, what, where, when. They stop exactly where the legal duty starts. Under HSWA 2015 the reporting question is not "did something happen" but "does this meet the s25 definition of a notifiable event", because that single determination triggers the duty to notify WorkSafe as soon as possible (s56), the duty to preserve the site (s55), and the duty to keep the record for at least five years (s57). This form runs that test on the page, in plain language, at the moment of reporting.
Near misses go unrecorded because they "weren't injuries"
A notifiable incident under HSWA does not require anyone to be hurt. Immediate exposure to a serious risk is enough. Forms built around injury reporting systematically miss this category.
Records are not kept in a retrievable form
Section 57 requires notifiable-event records to be kept for at least five years. Loose forms in a job folder do not survive a staff change. This pack includes the register that holds them.
Who this is for
- Subcontractors and trade businesses
- A single form your crew can complete on site, that tells you immediately whether the event has to go to WorkSafe.
- Main contractors
- Standard reporting form issued to every subcontractor at induction, so incoming reports arrive in one consistent shape.
- Businesses building a SiteWise or Tōtika submission
- Prequalification asks for evidence of incident reporting and corrective action in use. This form plus its register is that evidence.
- Office, retail and light-industrial PCBUs
- The notifiable-event duties are not construction-specific — every PCBU carries them. The form is trade-neutral.
This is the reporting form. If you need the investigation that follows a serious event, or the register that tracks hazards rather than events, those are separate documents.
What's inside the template
Word — 9 pages (form + guidance + register) · Formats: DOCX
- Section 1 — Event detailsDate, time, location, PCBU, person reporting, persons involved, witnesses.
- Section 2 — What happenedFree-text narrative plus a structured sequence-of-events prompt so the account is usable months later.
- Section 3 — Injury or illnessNature, body part, treatment given, referral. Distinguishes first aid from medical treatment from notifiable injury.hswa 25 b
- Section 4 — Notifiable event testThe decision gate. Three yes/no branches — death, notifiable injury or illness, notifiable incident — each with the statutory trigger written out in plain language.hswa 25 a
- Section 5 — Immediate actions takenMade safe, site preserved, area isolated, plant quarantined, who was told and when.hswa 55
- Section 6 — Notification recordWhether WorkSafe was notified, by whom, at what time, reference number, and whether a written notice was subsequently required.hswa 56
- Section 7 — Immediate cause and contributing factorsShort-form causal capture. Full analysis lives in the Investigation Report where the event warrants one.
- Section 8 — Corrective actionsAction, owner, due date, hierarchy-of-control level, closed-out date and signature.grwm 5
- Section 9 — Sign-offReporter, supervisor, and PCBU representative, with the review date that starts the retention period.hswa 57
- Appendix A — Incident registerRunning log of every event, with notifiable flag and corrective-action status. This is the five-year record.
- Appendix B — Guidance notesHow the notifiable tests apply, worked examples for common trade scenarios, and what "as soon as possible" means in practice.
Compliance checklist
HSWA 2015 ss.25, 55, 56, 57
The notifiable-event duties sit across four sections of HSWA 2015. The form is structured so each one is discharged in sequence rather than reconstructed afterwards.
- s25Determine whether the event is a notifiable event — death, notifiable injury or illness, or notifiable incident→ Section 4 — Notifiable event test
- s23–s24Apply the definitions of notifiable injury or illness and notifiable incident→ Sections 3 and 4, with the statutory triggers restated in Appendix B
- s55Take all reasonable steps to preserve the site until an inspector releases it→ Section 5 — Immediate actions taken
- s56Ensure the regulator is notified as soon as possible after becoming aware of a notifiable event→ Section 6 — Notification record
- s57Keep a record of each notifiable event for at least 5 years→ Section 9 and Appendix A — Incident register
- GRWM reg 5Identify hazards that could give rise to reasonably foreseeable risks→ Section 8 — Corrective actions, cross-referenced to the Hazard Register
How this template compares
Reviewed by OH Professionals
Written and reviewed by the occupational health and safety team at OH Consultant. The notifiable-event logic in Section 4 is drawn directly from the HSWA 2015 definitions rather than adapted from Australian incident-reporting practice — the two regimes differ in what triggers notification, and a form built on the Australian tests will under-report in New Zealand.
Legislation referenced
- Health and Safety at Work Act 2015 — Section 25 — Meaning of notifiable event ↗
- Health and Safety at Work Act 2015 — Section 36 — Primary duty of care ↗
- Health and Safety at Work Act 2015 — Section 55 — Duty to preserve sites ↗
- Health and Safety at Work Act 2015 — Section 56 — Duty to notify notifiable event ↗
- Health and Safety at Work Act 2015 — Section 57 — Duty to keep records of notifiable events ↗Records must be kept for at least 5 years from the date notice is given.
- Health and Safety at Work (General Risk and Workplace Management) Regulations 2016 — Regulation 5 — Duty to identify hazards ↗
Frequently asked
When do I have to notify WorkSafe?+
As soon as possible after you become aware that a notifiable event has occurred — that is the s56 duty. A notifiable event under s25 is a death, a notifiable injury or illness, or a notifiable incident arising from the conduct of your business or undertaking. Section 4 of the form walks the three branches so the decision is made at the time of reporting rather than later.
Does someone have to be injured for an event to be notifiable?+
No. A notifiable incident is defined by exposure to a serious risk, not by the outcome. An unplanned collapse, an uncontrolled release, or an electrical incident can be notifiable with nobody hurt at all. This is the single most common reason NZ businesses under-notify, and it is why the form treats near misses as first-class events rather than an afterthought.
How long do I need to keep incident records?+
Section 57 requires a record of each notifiable event to be kept for at least 5 years from the date notice of the event is given to WorkSafe. Appendix A of this pack is the register that holds those records in one retrievable place.
Do I have to preserve the site?+
Where a notifiable event has occurred, section 55 requires the PCBU who manages or controls the workplace to take all reasonable steps to ensure the site is not disturbed until an inspector releases it — subject to the exceptions in the Act for helping an injured person, making the site safe, and similar. Section 5 of the form captures what was done and why.
Is this the same as an investigation report?+
No. This form records the event and discharges the notification duties. Where an event warrants root-cause analysis, the Incident Investigation Report is the separate document that does that work, and it references the report number from this form.
Will this satisfy SiteWise or Tōtika?+
Prequalification schemes ask for evidence that an incident reporting and corrective-action process is actually in use — not merely that a form exists. This document gives you the form and the register; the evidence comes from completed records accumulated over time. It supports a submission, it does not substitute for one.
Is it specific to construction?+
No. The notifiable-event duties in HSWA apply to every PCBU regardless of sector, and the form is written to be trade-neutral. The worked examples in Appendix B cover construction, workshop and light-industrial scenarios.