Operations Manager

Near Miss Form

Please Note

All reportable incidents must be reported.
All reported incidents are:
- used for trend analysis, future planning and reporting to the appropriate authorities as required.
- kept on file in the CYC Waihola office.
It is preferable that this form is completed within 24 hours of the incident occurring
All incidents on the Incident Severity Table that are level 3 and above will be reported on the National Incident Database (NID) and incidents level 6 and above are reported to Worksafe as well
The contents of form will be kept confidential to CYC Waihola management
- Only summarised details will be given discerningly by the Operations Manager to caregivers and outside agencies if requested

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CYC Waihola would like to thank-you for agreeing to complete this reference form for the applicant – we really appreciate your time and responses.

The responses you make are made in confidence to the CYC office only and are not shown to the applicant unless you agree that we may discuss your responses with them. With this in mind we do ask that you are as honest as possible in your answers.
If you are a member of the applicant’s immediate family (i.e. a parent, child or spouse) then unfortunately you cannot complete this reference for them.

All reportable incidents must be reported.
All reported incidents are:
- used for trend analysis, future planning and reporting to the appropriate authorities as required.
- kept on file in the CYC Waihola office.
It is preferable that this form is completed within 24 hours of the incident occurring
The contents of form will be kept confidential to CYC Waihola staff and future camp directors only
- Only summarised details will be given discerningly by the Operations Manager to caregivers and outside agencies if requested