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Incident Report Form

Student Name*
First Last
Student email/contact info
When possible, enter student email or cell #
Program*
- Environmental Technician
- Forestry Technician
- Outdoor Adventure
- Outdoor Adventure Naturalist
- Urban Forestry
Course Leader Name*
First Last
Instructor Name*
First Last
Date of Incident*
MM slash DD slash YYYY
Program Activity*
Course Day #*
# Staff*
# Participants*
Weather at Time of Incident*
Type of Incident*
- Injury
- Illness
- Motivation/Behaviour
- Near Miss
Is this a lost-day case?*
- Yes
- No
Did the victim leave the field?*
- Yes
- No
Evacuation Method*
- Unassisted (walk, bike, ski, etc...)
- Litter
- Vehicle
- Air-Evac
- No Evac
Where was the drop-off location?
- Hospital
- Home
- College
Did the victim return to the course?*
- Yes
- No
Type of injury
- Bruise, contusion or similar soft-tissue trauma
- Ligament sprain
- Muscle strain
- Frostbite
- Fracture
- Dislocation
- Head injury WITHOUT loss of consciousness
- Head injury WITH loss of consciousness
- Near drowning or other submersion
- Immersion foot
- Tendonitis
- Eye injury
- Dental or tooth-related
- Burn
- Blisters(s)
- Laceration
- Skin abrasion
- Sunburn
- Other
Please provide details*
Anatomical Location of Injury (indicate left/right)*
Type of Illness
- Allergic reation MILD, localized
- Allergic reation Severe, generalized
- Allergic reaction ANAPHYLAXIS
- Hypothermia or heat illness (specify temp)
- Upper respiratory illness
- Upper respiratory illness (runny nose, congestion, "cold")
- Upper respiratory illness (other)
- Chest pain or cardiac condition
- Abdominal or other gastrointestinal problem including diarrhea
- Apparent food-related illness
- Non-specific fever illness
- Urinary tract infection
- Skin infection
- Eye infection
- Other
Please provide details*
Immediate Cause (prioritize if needed 1,2,3)*
- Fall on snow
- Fall on rock
- Fall/slip on trail
- Dehydration
- Cold exposure
- Technique
- Pre-existing medical condition
- Overuse injury
- Failed to follow instructions
- Carelessness
- Exceeded ability
- Exhaustion
- Psychological
- Misbehaviour
- Supervision
- Instruction
- Equipment
- Weather
- Other
Please provide details*
Narrative (what and how)*
In-field management (treatment, diagnosis, etc.)*
Follow-up (outcome, transport, location)*
Report prepared by:*
Date*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

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Perth

7 Craig St Perth, Ontario K7H 1X7

613-267-2859

Online

1385 Woodroffe Ave Ottawa, Ontario K2G 1V8

613-727-4723

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