Incident Report Form (Page 2 of 2) in pdf

Patient Male Female

Name_______________________

Address

_________________________________

______________

Who to Notify

_________________________

Contact Phone No(s)

____________________

Action taken

Search First Aid DRABC

Pressure Bandage CPR

Warming Cooling Party Sent

for Assistance

Additional Information__________________________________________________________________

__________________________________________________________________________________________

Assistance Required (Specify qualifications and numbers of helpers or teams required)

Personnel Paramedic Doctor Search Rescue/Recovery

Medication Water Food Shelter

Other ________________________________________________________

Communications Available (e.g. Mobile No. / CB channel) _____________________________

For emergencies, dial 112 from a mobile phone, or 000 from a landline.

Time of call: _____________

Planned Action (If moving give Route and Map Coordinates of destination) Remain at site

Evacuate to Track Road Track Junction Shelter Natural Feature Helipad

Additional Information ________________________________________________________________

Evacuation Plan / Requirements Walk out Improvised Stretcher Stretcher Ambulance Helicopter

Winch Helipad

Additional Information_________________________________________________________________

__________________________________________________________________________________________

This form is intended to help your decision-making in a stressful situation, provide essential

information to those called upon to assist, and record details for insurance claims. Send one copy of the

information with any party sent out for help. Keep one and continue to record relevant information.

(For example, log observations of the patient’s vital signs, times of events, actions and communications, details

of parties sent out, self-sufficiency of the party - equipment, physical and psychological condition of members)

__________________________________________________________________________________________

Forward a copy to the Safety & Training Officer or another Committee Member as soon as

possible

Incident Report Form Page 2