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The template records injury type, injury location, where the accident occurred, and how it happened, including questions about task training, vehicle involvement, and significant risks. It also documents potential harm, preventive steps, required actions with responsible persons and deadlines, and any initial needs assessment when a doctor visit is required.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/farm-incidentnear-miss-report-emergency-contact-and-incident-details-form/248876/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/farm-incidentnear-miss-report-emergency-contact-and-incident-details-form/248876.png","ImageObject",442,249,{"name":88,"@type":89},"Dipper","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-25","2026-09-12",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",8,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What emergency contacts are listed for an incident?","Question",{"text":109,"@type":110},"The form instructs contacting emergency services at 111 and calling WorkSafe at 0800 030 040.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Which accident and injury details does the form collect?",{"text":114,"@type":110},"It collects date and time, whether it is a near-miss or treatment level, injury nature categories, injury location, where the accident happened, and how the accident happened.",{"name":116,"@type":107,"acceptedAnswer":117},"How does the form handle significant risk and risk register documentation?",{"text":118,"@type":110},"It asks whether a significant risk was involved, what that risk was, and whether the risk is on the risk register, with Yes/No selections.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},248876,1791462496,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},1374404997633,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","WSNZ_ 2072_APR 16  \n\n| Date of issue: |  |\n| --- | --- |\n\nFARM INCIDENT/NEAR-MISS REPORT  \nIn case of an emergency:  \n– Contact emergency services: 111  \n– Call WorkSafe: 0800 030 040  \nPersonal details  \n\n| NAME: | PHONE NUMBER: |\n| --- | --- |\n| ADDRESS: | DATE OF BIRTH: |\n|  | SEX:  Male  Female |\n\nEmployment details  \n\n| FARM NAME: |  | JOB TITLE: |  |\n| --- | --- | --- | --- |\n|  Permanent |  Casual |  Contractor |  Visitor |\n\nAccident details  \n\n| DATE: |  Near-miss |  No treatment |  First aid |  Doctor |  Hospital |  Serious harm |\n| --- | --- | --- | --- | --- | --- | --- |\n| TIME: |  AM |  PM | Hours at work: |  | Date reported: |  |\n\nNature of injury  \n\n|  Strain/sprain |  Cut |  Head injury |  Fracture/break |  Gradual process |  |\n| --- | --- | --- | --- | --- | --- |\n|  Bruising |  Burns |  Poison/chemical |  Multiple injuries |  No injury |  |\n| LOCATION OF INJURY (CIRCLE LOCATION) |  | WHERE DID THE ACCIDENT HAPPEN? (EG SHED, PADDOCK ETC) |  |  |  |\n| \u003Cbr>\u003Cbr>L R\u003Cbr>Back | \u003Cbr>R   L\u003Cbr>Front |  |  |  |  |\n|  |  | HOW DID THE ACCIDENT HAPPEN? |  |  |  |\n| WAS THE PERSON TRAINED FOR THE TASK THEY WERE DOING? |  |  |  |  Yes |  No |\n| IF A VEHICLE WAS INVOLVED, RECORD TYPE OF VEHICLE |  |  |  |  |  |\n| WAS A SIGNIFICANT RISK INVOLVED? |  |  |  |  Yes |  No |\n| IF YES, WHAT WAS THE SIGNIFICANT RISK? |  |  |  |  |  |\n| IS THE RISK ON THE RISK REGISTER? |  |  |  |  Yes |  No |\n\n\n| WHAT HARM COULD HAVE HAPPENED? |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| STEPS TAKEN TO PREVENT A SIMILAR EVENT HAPPENING AGAIN |  |  |  |  |  |\n| SPECIFIC ACTIONS REQUIRED | PERSON RESPONSIBLE |  | BY WHEN |  | DATE COMPLETED |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n| INITIAL NEEDS ASSESSMENT (ONLY COMPLETE IF A DOCTOR’S VISIT WAS REQUIRED) |  |  |  |  |  |\n|  Able to continue full duties |  |  Able to do light duties |  |  Unable to work |  |\n|  Help available at home |  |  Assistance required at home |  |  Transport assistance needed |  |\n| Form completed by |  |  |  |  |  |\n| NAME: |  |  | POSITION: |  |  |\n| SIGNED: |  |  | DATE FORM WAS COMPLETED: |  |  |","cbCailwOIX5bjMwP","https://ap.wps.com/l/cbCailwOIX5bjMwP","pdf",55819,"English","# Personal details\n# Employment details\n# Accident details\n# Nature of injury\n# Incident circumstances and risk assessment\n# Potential harm and prevention\n# Required actions and responsibilities\n# Initial needs assessment","[{\"question\":\"What emergency contacts are listed for an incident?\",\"answer\":\"The form instructs contacting emergency services at 111 and calling WorkSafe at 0800 030 040.\"},{\"question\":\"Which accident and injury details does the form collect?\",\"answer\":\"It collects date and time, whether it is a near-miss or treatment level, injury nature categories, injury location, where the accident happened, and how the accident happened.\"},{\"question\":\"How does the form handle significant risk and risk register documentation?\",\"answer\":\"It asks whether a significant risk was involved, what that risk was, and whether the risk is on the risk register, with Yes/No selections.\"}]","FARM INCIDENT/NEAR-MISS REPORT - Emergency Contact and Incident Details Form | PDF",1789248444]