Health and safety incident report form

Any information supplied below will be kept confidential and remains the property of the Maritime Union of New Zealand.

Your Name (required)

Your Email (required)

Your Mobile or Telephone Number (required)

Are you a MUNZ member?(required)
YesNo

Your MUNZ Branch (if applicable)

Port or location where the incident happened (required)

Date and time of incident

Name of person(s) involved in incident (if known)?

Was anyone injured?

Was this a Lost Time Injury (LTI) - tick box if yes

Was this a Managed Time Injury (MTI) - tick box if yes

Who was incident reported to at port? (Name/position)

What was response when incident was reported?

When was incident reported? (Date/time)

Describe the incident

Upload a photo or document about incident

 

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