Incident Report Form printable pdf download

Georgia College

Outdoor Education

Incident Report Form

Property Damage  NO  YES.

Accident/Incident Report forms (I/A) are completed by OE Staff or program

 Vehicle  Equipment  Facility  Other: ____________________

staff and normally signed by the injured party. Submit this form to the fulltime

direct supervisor for review, presentation, and follow up by OE Staff.

Type of Illness. Choose most significant:

Organization: Georgia College Outdoor Education

 Abdominal pain

 Heat illness

 Allergic reaction

 Hypothermia

Program Type: Academic Class

OC Program (circle one)

 Altitude illness

 Nausea or vomiting

 Apparent food-related illness

 Nonspecific fever illness

Program Location:

 Chest pain or cardiac condition

 Skin infection

Course/Program Name: _____________________________________

 Dehydration

 Upper respiratory illness

 Diarrhea

 Urinary tract infection

Victim’s Name(s): _________________________________________

 Eye or ear infection

 Other (explain)

 Flu symptoms/"cold"

Age: _______________  Male Female  Staff  Student/Client

Incident Date: _____/_____/_____ Time _____:_____ a.m./p.m.

Type and Location of Injury. Select all significant types of injury and mark

and label the affected areas on the diagram:

Type of Environment. Check all that apply:

 Athletic Injury (

)

sprain, strain

 Lake  River  Ocean  Forest  Cliff  Challenge Course

 Dental

 Indoors  Other: ___________________________________________

 Eye injury

 Frostbite

Type of Incident. Check all that apply:

 Head injury

 Near Miss  Illness  Injury  Motivation/Behavioral  Property

 Near drowning or immersion

 Skeletal (dislocation, fracture)

Did the patient leave the field?  NO  YES, Date: ____/____/____

 Soft tissue (bruise, burn, blister,

If yes, provide the following information:

wound, abrasion)

Evacuation Method:  Unassisted  Walking Assisted  Litter Carry

 Sunburn

 Vehicle  Helicopter  Other_____________________________

 Other (explain)

Did the patient visit a medical facility?

 NO  YES, Outpatient only  YES, Admitted

Victim returned to the course?  NO  YES, Date ____/____/____

(Over)

Developed from WRMC Incident Data Reporting Form September 2001

Form Revised S11

Incident Report Form

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