Incident Report Log

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SURF LIFE SAVING AUSTRALIA
Form no: 161/07
INCIDENT REPORT LOG
Name of Club / Service: _________________________
State: ___________________________
Conditions at time of incident (if relevant):
Date: _____/______/______
Time: ___________ am / pm
Wind:
Calm
Slight
Moderate
Location (beach/suburb): ____________________________
Weather:
Fine
Overcast
Rain
Name of Victim: ____________________________________
Seas:
Small
Medium
Large
Water Surface:
No Chop
Avg Chop
Large Chop
Age: _________
DOB: _____/______/_______
M / F
Wave Type:
Surging
Spilling
Plunging
Address if known: __________________________________
Type of incident:
Description of incident:
Mechanism of incident:
(may choose more than one)
(please use back if needed)
(what went wrong?)
Major First Aid
Minor First Aid
_____________________________________
_____________________________________
Major Rescue
Search & Rec.
_____________________________________
_____________________________________
Member Injury
Employee Injury
_____________________________________
Carnival Incident
Complaint
Location of incident:
_____________________________________
Drowning
Near Drowning
Other ___________________________
In water
On beach
Nature of injury:
On rocks
Other _____________
Patient is:
and…
Marine sting, type __________________
In flags
Abrasion / graze
Blisters
Public
SLSC Member
Outside but near flags
Open wound / laceration / cut
Employee
Other ________
< 1km from patrolled area
Bruise / contusion
1 - 5km from patrolled area
Inflammation / swelling
Type of activity at time of incident:
> 5km from patrolled area
Fracture (including suspected)
Dislocation / subluxation
Swimming/wading
Body boarding
Who first sighted the rescue/incident:
Sprain
Sprain
Walking/playing near water
Overuse injury
Concussion
Riding other craft
(e.g. public) ___________________________
Cardiac problem
Rock fishing
Other fishing
Respiratory problem
Using a motorised water craft (rec)
Loss of consciousness
Water skiing
Who conducted the rescue/incident:
Heat stroke / Heat exhaustion
SCUBA/skin diving
Hypothermia
Sunburn
(e.g. lifesaver) _________________________
Wind/kite surfing
Sailing
Suspected spinal
Deceased
Rock walking
Suspect suicide
Other ___________________________
Patrolling:
IRB
PWC
Main language spoken:
Unknown
Beach
4WD
JRB/ORB
Attempting a rescue
___________________ Or
English
Body region injured (please circle):
Training for (please be very specific)
Non-English Speaking
Unknown
________________________________
Carnival official doing _______________
Referral:
Competition in ____________________
No referral
Medical practitioner
IRB Competition:
Driver
Physiotherapist
Crew
Patient
Ambulance transport to _____________
Surf boat crew position: _____________
Hospital
X-ray
Administrative
Fundraising
Peer counselling
Pro. counselling
Water safety
Junior activities
Other club activity _________________
Other ___________________________
Other services:
Unknown
Fire/Rescue
Police
JRB / ORB
Helicopter
Initial treatment:
Experience in activity:
Investigation required
Worker Compensation required
None given – not required
3 years +
1-3 years
Other ___________________________
None given – patient refused
1 year
No experience
None given – referred elsewhere
RICE
ICE
Treating person:
Other contributing factors:
Cleaned
Medical practitioner
Nurse
Negotiating the break
Dressed (incl. bandage)
Ambulance
Physio
Returning to shore
Sling / splint
Chiropractor
First Aid Off.
Dumped
Shore break
Spinal collar
Lifesaving
Lifeguard
Lost control of own craft
Massage / stretching
Other ___________________________
Other person lost control of craft
Strapping / taping only
Stitches
Freak wave
Sand bank
Person completing form:
Medication
Pot hole
Slippery rocks
Suspected alcohol
Suspect drugs
Prescription written
Name: _______________________________
Rip type _________________________
Resuscitation
Position: _____________________________
Slip / trip / fall
Assault
(please fill in other side of form)
Collision with _____________________
Rescue breathing
CPR
Phone: ______________________________
Mechanical malfunction
Oxygen therapy
Oxygen airbag
Email: _______________________________
Other ___________________________
Defibrillation (defib)
Unknown
Other ___________________________
Signature: ____________________________
Enter this form into the Incident Reporting Database
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