The first section asks for the basic information. Please fill all of this out. If you are willing, we'd also like to have more detailed information. Full narratives, analysis, and suggestions for others are greatly appreciated.
The person filling out this form should be familiar with the circumstances of the injury - either the person(s) involved or a rescuer involved in the incident. Please provide contact information so we can follow up with questions.
Reports submitted here will be used for safety analysis, compilation of data to identify common occurrences, and may be published in part or in full. If you would prefer your report is not published, please check the box at the end.