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* 1. Person completing report

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* 2. Date and time of incident

Date
Time

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* 3. Location of where the incident occurred

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* 4. List any other Mauao Adventures staff members or volunteers who were onsite during the incident, and their roles, i.e Tapae - Kaitiaki Matua

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* 5. List any other relevant witnesses to the incident, include their names and what they were doing at the location, if known. If unknown, provide a brief description of them.

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* 6. Details of your expected duties for the day

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* 7. What was the direct impact resulting from the incident? Tick all relevant occurrences.

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* 8. Provide detail about the direct impact of the incident using the following sequence:
Impact - What happened - How it happened - Why it happened

Example:
Impact - broken collar bone
What - kid falling off a rock
How - slipped while jumping off a rock
Why - didn't listen to instruction that he wasn't allowed on the rocks

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* 9. Details of the directly impacted person or people, if known. Include name, age, gender, phone or email, and area of residence. If any details are unknown, please provide any description to help determine who they are.

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* 10. Detailed description of the incident. Include things leading up to the incident, where in the location it took place, how the incident happened, who played what part, and all other information of relevance.

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* 11. How was the incident addressed and what part did you and Mauao Adventures staff play in addressing the incident?

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* 12. Is there anything that Mauao Adventures, yourself or your fellow staff could have done to eliminate or prevent the incident from happening? List any suggested actions that could have taken place, any resources and equipment that would have helped, or any policies and procedures that either weren't followed or could be implemented.

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* 13. Other than what's been listed in Question 10, do you have any suggestions for Mauao Adventures to implement that can eliminate or prevent this from happening again?

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* 14. What immediate impact, aside from what's already been mentioned, has this had on you personally?

Please keep management informed of any delayed or ongoing impacts you are personally experiencing as a result of this incident.

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* 15. On a scale of 1-5 with 1 being the least likely, rate the likelihood for this occurring again if not addressed.

Unlikely Highly likely
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 16. On a scale of 1-5, with 1 being the least severe, rate the level of severity of the incident

Minor incident Major incident
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 17. Please acknowledge that you will email the following incident-related images to kiaora@mauaoadventures.co.nz as soon as possible after completing this form.

- Photo or drawing that clearly shows where on the body any injury occurred
- Photo or drawing that clearly illustrates where at the location the incident occurred. Mark any points of interest relating to this incident on the illustration

Admin will make contact to get this form signed.

Signed: __________________________________________________________________________________________

Date: _____________________________________________________________________________________________

Reviewed by: ___________________________________________________________________________________

Date reviewed: _________________________________________________________________________________

Actions recommended by reviewer:

T