Incident Report Form printable pdf download

Incident Report Form

To be completed by activity organizers/walk leaders as soon as practical after the

incident. This report should be kept by the club secretary as a formal club record. In the

event of any serious injury (an injury requiring medical treatment) copies of the incident

report must be forwarded to the Insurance Convener for the State of the Member Club.

Provide relevant information and mark the appropriate option(s).

Trip information

Date _________________ Time ______________ Destination _________________________________

Leader __________________________________________________________

Trip Contact Officer __________________________________Phone No. _______________________

Number of Walkers ______________ Experienced ____________ Intermediate ______________

Inexperienced ____________

Type of incident

Delay Lost party members Fall Injury Snakebite Insect bite Illness Fatigue Hyperthermia

Hypothermia

Additional Information _________________________________________________________________

____________________________________________________________________________________

Witnesses _______________________________________________________________________________

__________________________________________________________________________________________

Location of incident

Map ____________________ Datum ____________ Map Coordinates _________________________

Elevation _________m Lat & Long (GPS) _________________________________________________

Terrain Open Closed canopy Water course Slippery Rocky Steep Ridge Gorge

General Description ____________________________________________________________________

__________________________________________________________________________________________

Weather Hot Warm Cool Cold Sunny Windy Foggy Cloudy Rain

Other____________________________________________________________________________________

First Aid Assessment Overall condition Good Fair Poor Serious Critical

Primary Injury/Situation _______________________________________________________________

__________________________________________ _______________________________________________

Secondary Injury(s) _____________________________________________________________________

__________________________________________ _______________________________________________

Incident Report Form