Incident Report Form
If anyone is seriously injured, call 911 immediately. Once the situation is stable, call S&S at (603) 646-4000.

Instructions for writing incident reports:
- Your first priority is to properly care for the victim. Never let paperwork get in the way of proper emergency situation management.
- Incident reports should be filled out whenever a participant is seriously injured or ill, or when a situation occurs that could easily have led to an injury but for some reason didn't (A "Near Miss"). One rule of thumb is that if you have to deal with a situation more than once, it is worth filing an incident report.
- When performing medical care in the field, use SOAP notes found in First Aid Kits to document patient condition and medical treatment provided.
- Describe in detail what occurred, the technical conditions and the actions of all people involved.
- Do not attempt to analyze the causes of the incident. Stick to the hard facts. We will analyze later in a review meeting.
- Include information about when you contacted 911, S&S, or OPO
- Be sure to submit this information as soon as possible.
- For anything other than very routine incidents, call S&S so they can bring OPO up to date.

Emergencies are divided into 3 levels:

Level 1: If death occurred, or medical care will be required; If there was a structure/forest fire affecting the trip; If there was a missing person with potential for search or serious injury; or if there has been a near-miss with high likelihood of accident in the near future involving injury to you or others.
1. Secure the scene and prevent further accident/injury. 2. Do first aid if required; call 911 if life threatening. 3. Notify Safety and Security (603-646-4000): Have ready: participant's name/class, date, time, place, and nature of the problem. Safety and Security will contact an OPO staffer. Stay by the phone until contacted by an OPO or college official. If the problem is solved, call back to cancel. Fill out DOC/OPO Field Accident Report form (in first aid kit); update as needed.
Level 2: If it's not a level 1 incident; and if there is property damage/loss in excess of $500; or if there is any damage to another vehicle; Call S&S within 24 hours (603-646-4000).
Level 3: If it's not a level 1 or level 2 incident; and if you need to treat any injury more than once; or if there is damage to College equipment in excess of $50; If a person was unexpectedly separated from the group for a significant time period; If a near miss happened that would be worth noting for the record; Fill out the Incident Report form and discuss with your club partner within one week.
Name of leader/person making report
Your answer
Your phone number
Your answer
Date of incident
MM
/
DD
/
YYYY
Time of incident
Time
:
Location of incident
Your answer
Club/program
Your answer
Activity
Your answer
Weather
Your answer
Describe in detail what happened:
Your answer
How did you respond in the field?
Your answer
Relevant conditions (high water, terrain, technical level, etc.):
Your answer
Participant name:
Your answer
Participant age:
Your answer
Participant gender:
Your answer
Nature/extent of injury/illness: (describe type, severity, and location if injury)
Your answer
Type of footwear, gear, clothing used by participant:
Your answer
Medical treatment if any:
Your answer
Was participant evacuated (if so, how)?
Your answer
Was participant taken to medical facility?
If so, where?
Your answer
Treating physician?
Your answer
Recommendations for ongoing care/treatment:
Your answer
Witnesses: (name, phone number, and role on trip of anyone directly involved or witnessing. Include any emergency responders, state agencies, or other organizations involved)
Your answer
Was safety and security notified?
When?
Your answer
Did you talk to OPO? Who/when?
Your answer
What did the group do afterward?
Your answer
List other participants not involved:
Your answer
Leader/reporter signature
Your answer
Date
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy