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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.
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* Indicates required question
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?
*
Incident
Near-miss
Unsure
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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