WAC Incident / Near Miss Form
Tell us what happened so the club can learn from it! Names will be removed before this information is shared.
Your name (will not be shared outside the RMC)
Your answer
Your email address
In case we have any follow-up questions
Your answer
Was this an incident or near-miss?
Location
Your answer
Name of outing
Your answer
Date of Incident / Near-Miss
MM
/
DD
/
YYYY
Person(s) involved
Your answer
Activity
Examples: rock climbing, skiing, cooking, hiking, belaying
Your answer
Environmental conditions
Examples: muddy ground, snowing, low visibility, wet rock, glaring sun
Your answer
Narrative
In a few sentences, describe what happened. Were any injuries sustained?
Your answer
Contributing factors
In a sentence or two, describe what factors you think contributed to this incident (or near-miss). Examples: fatigue, weather, inadequate training, poor site selection, time pressure, distraction, poor self-care.
Your answer
Anything to learn from this incident?
Is there anything we should do differently next time?
Your answer
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