JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
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.
Sign in to Google
to save your progress.
Learn more
* 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
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
