RNZYS Incident report form

For the purposes of incident reporting at RNZYS the following definitions apply
Injury: Harm to a person resulting in first aid or medical treatment
Near miss: an incident that did not result in injury, illness, or damage but had the potential to do so.
Significant property damage: damage that renders equipment unfit or unsafe to use.

NOTE: serious injuries, accidents or incidents must be reported to Maritime NZ
Find out your legal reporting obligations here.

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Name of person reporting incident *

First

Last

Role *Please selectRNZYS Staff, Official or VolunteerSkipper of vessel participating in RNZYS eventRNZYS Member or GuestOther

Phone *

Email *

I am reporting a *

• Injury
• Near miss
• Significant property damage

See above for definitions. Select all that apply.

Did the incident occur on-water? *

• Yes
• No

Did the incident involve a collision with another vessel? *

• Yes
• No

Location of Incident *

Please be specific.

Date and Time of incident *

Date

Time

Details of person/s involved in incident *

Please include full name/s and contact details if known. For on water collisions please include details of other parties involved including any witnesses if applicable.

Purpose for visiting RNZYS *

• RNZYS Member or Guest
• Volunteering
• Participating in on-water event
• Staff member
• Contractor

Select all that apply

measures aid What

Please describe the incident in detail *

Please include any details of how the incident was initially reported. (e.g radio assistance requested, RNZYS staff notified)

Details of first aid provided and/or any medical attention *

e.g bandages or ice applied? Emergency services called or taken to medical centre?

Name of event or purpose for being on the water *

Details of weather and on water conditions *

Include wind strength, direction & sea state

Could this incident have been avoided? *

• Yes
• No
• Unsure

What measures could have been taken to avoid the incidient? *

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