Outdoor Education Incident Report Form - New Zealand

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Outdoor Education/Recreation Incident Report
P
Notes: Fields marked in
red
with
*
are compulsory fields.
Please
as applicable in fields below.
1. General Incident Information
Incident report # (from database) _______
Severity rating*: actual* ___ potential* ___
Region*:
(see severity scale)
Eg. Southland, Taranaki
Location of incident*
(Name of: river, track, rock climb, etc.)
Grid reference:
Date of incident*:
Time*
(24 hr, e.g. 2pm = 1400) : ………….
Incident type*
Weather at time of incident*
Communications used
¨
Mountain radio
¨ Flare
¨
Injury
Fine
¨
¨
¨
¨ Wet
¨
VHF radio
¨ Locator beacon
¨
Illness
Hot
¨
¨
¨
¨ Cold
¨ Mobile phone
¨ Messenger (person)
¨
Psychological/emotional
Calm
¨
¨
¨
¨ Windy
¨
Satellite phone
¨ n/a
¨
Equipment loss/damage
______
¨ Avalanche transceiver ¨
Other
¨
Fatality
¨
Missing/overdue
Is this a lost day case?*
¨
Near Miss
No. of people involved*
______
¨
Yes
¨ No
# days lost _______
2. Information on person/s involved in incident.
(Complete for each person. More names? Add to a separate sheet)
First name: ____________________
First name: ____________________
First name: ____________________
Last name: ____________________
Last name: ____________________
Last name: ____________________
Age*:
Gender*:
M F
Age*:
Gender*:
M F
Age*:
Gender*:
M F
Ethnicity*:
Ethnicity*:
Ethnicity*:
¨
NZ
¨
NZ
¨
NZ
¨
Maori
¨
Maori
¨
Maori
¨
Pacific Is.
¨
Pacific Is.
¨
Pacific Is.
¨
Asian
¨
Asian
¨
Asian
¨
Other __________
¨
Other __________
¨
Other __________
¨
Unknown
¨
Unknown
¨
Unknown
Evacuation Method*:
Evacuation Method*:
Evacuation Method*:
¨
Walked out
¨
Walked out
¨
Walked out
¨
Stretcher
¨
Stretcher
¨
Stretcher
¨
Vehicle
¨
Vehicle
¨
Vehicle
¨
Helicopter
¨
Helicopter
¨
Helicopter
¨
Boat
¨
Boat
¨
Boat
¨
n/a
¨
n/a
¨
n/a
Injury type *
Injury type *
Injury type *
Illness type*
Illness type*
Illness type*
¨
Abdominal problem
¨
Burn
¨
Burn
¨
Burn
¨
Abdominal problem
¨
Abdominal problem
¨
Blister
¨
Allergic reaction
¨
Blister
¨
Blister
¨
Allergic reaction
¨
Allergic reaction
¨
Bruise
¨
Altitude illness
¨
Bruise
¨
Bruise
¨
Altitude illness
¨
Altitude illness
¨
Asthma
¨
Concussion
¨
Concussion
¨
Concussion
¨
Asthma
¨
Asthma
¨
Eye injury
¨
Chest pain
¨
Eye injury
¨
Chest pain
¨
Eye injury
¨
Chest pain
¨
Diarrhoea
¨
Dislocation
¨
Dislocation
¨
Dislocation
¨
Diarrhoea
¨
Diarrhoea
¨
Eye infection
¨
Dental
¨
Dental
¨
Dental
¨
Eye infection
¨
Eye infection
¨
Frostbite
¨
Food poisoning
¨
Frostbite
¨
Food poisoning
¨
Frostbite
¨
Food poisoning
¨
Hypothermia
¨
Fracture
¨
Fracture
¨
Fracture
¨
Hypothermia
¨
Hypothermia
¨
Head injury
¨
Heat stroke
¨
Head injury
¨
Head injury
¨
Heat stroke
¨
Heat stroke
¨
Laceration/cuts
¨
Menstrual
¨
Laceration/cuts
¨
Laceration/cuts
¨
Menstrual
¨
Menstrual
¨
Non-specific fever
¨
Muscle strain
¨
Muscle strain
¨
Muscle strain
¨
Non-specific fever
¨
Non-specific fever
¨
Near drowning
¨
Skin infection
¨
Near drowning
¨
Near drowning
¨
Skin infection
¨
Skin infection
¨
Respiratory
¨
Punctures
¨
Punctures
¨
Punctures
¨
Respiratory
¨
Respiratory
¨
Urinary tract infection
¨
Skin abrasions
¨
Skin abrasions
¨
Skin abrasions
¨
Urinary tract infection
¨
Urinary tract infection
¨
Sprain
¨
Other __________
¨
Sprain
¨
Other __________
¨
Sprain
¨
Other __________
¨
Sunburn
¨
Sunburn
¨
Sunburn
¨
Tendonitis
¨
Tendonitis
¨
Tendonitis
¨
Psychological
¨
Psychological
¨
Psychological
¨
Other _________
¨
Other _________
¨
Other _________
3. Activity Information
Activity* (Choose the most appropriate activity the person was engaged in at time of incident)
¨
Abseiling
¨
Free time
¨
Rafting
¨
Solo
¨
Bungy Jumping
¨
Horse riding
¨
River crossing
¨
Surfing
¨
Camping
¨
Hunting
¨
Rock climbing
¨
Swimming
¨
Canoeing
¨
Initiatives
¨
Ropes
¨
Tramping
¨
Caving
¨
Kayaking
¨
Sailing
¨
Transportation
¨
Community service
¨
Land yachting
¨
Sea kayaking
¨
Tubing
¨
Cooking
¨
Mountain biking
¨
Skiing
¨
Windsurfing
¨
Cycling
¨
Mountaineering
¨
Snowboarding
¨
Waterskiing
¨
Field trip: (specify) _______
¨
Multisport/adventure racing
¨
Snow caving
¨
Other ______________
¨
Fishing
¨
Orienteering/Rogaining
¨
Snorkelling
Outdoor Education/Recreation Incident Report
P
Notes: Fields marked in
red
with
*
are compulsory fields.
Please
as applicable in fields below.
1. General Incident Information
Incident report # (from database) _______
Severity rating*: actual* ___ potential* ___
Region*:
(see severity scale)
Eg. Southland, Taranaki
Location of incident*
(Name of: river, track, rock climb, etc.)
Grid reference:
Date of incident*:
Time*
(24 hr, e.g. 2pm = 1400) : ………….
Incident type*
Weather at time of incident*
Communications used
¨
Mountain radio
¨ Flare
¨
Injury
Fine
¨
¨
¨
¨ Wet
¨
VHF radio
¨ Locator beacon
¨
Illness
Hot
¨
¨
¨
¨ Cold
¨ Mobile phone
¨ Messenger (person)
¨
Psychological/emotional
Calm
¨
¨
¨
¨ Windy
¨
Satellite phone
¨ n/a
¨
Equipment loss/damage
______
¨ Avalanche transceiver ¨
Other
¨
Fatality
¨
Missing/overdue
Is this a lost day case?*
¨
Near Miss
No. of people involved*
______
¨
Yes
¨ No
# days lost _______
2. Information on person/s involved in incident.
(Complete for each person. More names? Add to a separate sheet)
First name: ____________________
First name: ____________________
First name: ____________________
Last name: ____________________
Last name: ____________________
Last name: ____________________
Age*:
Gender*:
M F
Age*:
Gender*:
M F
Age*:
Gender*:
M F
Ethnicity*:
Ethnicity*:
Ethnicity*:
¨
NZ
¨
NZ
¨
NZ
¨
Maori
¨
Maori
¨
Maori
¨
Pacific Is.
¨
Pacific Is.
¨
Pacific Is.
¨
Asian
¨
Asian
¨
Asian
¨
Other __________
¨
Other __________
¨
Other __________
¨
Unknown
¨
Unknown
¨
Unknown
Evacuation Method*:
Evacuation Method*:
Evacuation Method*:
¨
Walked out
¨
Walked out
¨
Walked out
¨
Stretcher
¨
Stretcher
¨
Stretcher
¨
Vehicle
¨
Vehicle
¨
Vehicle
¨
Helicopter
¨
Helicopter
¨
Helicopter
¨
Boat
¨
Boat
¨
Boat
¨
n/a
¨
n/a
¨
n/a
Injury type *
Injury type *
Injury type *
Illness type*
Illness type*
Illness type*
¨
Abdominal problem
¨
Burn
¨
Burn
¨
Burn
¨
Abdominal problem
¨
Abdominal problem
¨
Blister
¨
Allergic reaction
¨
Blister
¨
Blister
¨
Allergic reaction
¨
Allergic reaction
¨
Bruise
¨
Altitude illness
¨
Bruise
¨
Bruise
¨
Altitude illness
¨
Altitude illness
¨
Asthma
¨
Concussion
¨
Concussion
¨
Concussion
¨
Asthma
¨
Asthma
¨
Eye injury
¨
Chest pain
¨
Eye injury
¨
Chest pain
¨
Eye injury
¨
Chest pain
¨
Diarrhoea
¨
Dislocation
¨
Dislocation
¨
Dislocation
¨
Diarrhoea
¨
Diarrhoea
¨
Eye infection
¨
Dental
¨
Dental
¨
Dental
¨
Eye infection
¨
Eye infection
¨
Frostbite
¨
Food poisoning
¨
Frostbite
¨
Food poisoning
¨
Frostbite
¨
Food poisoning
¨
Hypothermia
¨
Fracture
¨
Fracture
¨
Fracture
¨
Hypothermia
¨
Hypothermia
¨
Head injury
¨
Heat stroke
¨
Head injury
¨
Head injury
¨
Heat stroke
¨
Heat stroke
¨
Laceration/cuts
¨
Menstrual
¨
Laceration/cuts
¨
Laceration/cuts
¨
Menstrual
¨
Menstrual
¨
Non-specific fever
¨
Muscle strain
¨
Muscle strain
¨
Muscle strain
¨
Non-specific fever
¨
Non-specific fever
¨
Near drowning
¨
Skin infection
¨
Near drowning
¨
Near drowning
¨
Skin infection
¨
Skin infection
¨
Respiratory
¨
Punctures
¨
Punctures
¨
Punctures
¨
Respiratory
¨
Respiratory
¨
Urinary tract infection
¨
Skin abrasions
¨
Skin abrasions
¨
Skin abrasions
¨
Urinary tract infection
¨
Urinary tract infection
¨
Sprain
¨
Other __________
¨
Sprain
¨
Other __________
¨
Sprain
¨
Other __________
¨
Sunburn
¨
Sunburn
¨
Sunburn
¨
Tendonitis
¨
Tendonitis
¨
Tendonitis
¨
Psychological
¨
Psychological
¨
Psychological
¨
Other _________
¨
Other _________
¨
Other _________
3. Activity Information
Activity* (Choose the most appropriate activity the person was engaged in at time of incident)
¨
Abseiling
¨
Free time
¨
Rafting
¨
Solo
¨
Bungy Jumping
¨
Horse riding
¨
River crossing
¨
Surfing
¨
Camping
¨
Hunting
¨
Rock climbing
¨
Swimming
¨
Canoeing
¨
Initiatives
¨
Ropes
¨
Tramping
¨
Caving
¨
Kayaking
¨
Sailing
¨
Transportation
¨
Community service
¨
Land yachting
¨
Sea kayaking
¨
Tubing
¨
Cooking
¨
Mountain biking
¨
Skiing
¨
Windsurfing
¨
Cycling
¨
Mountaineering
¨
Snowboarding
¨
Waterskiing
¨
Field trip: (specify) _______
¨
Multisport/adventure racing
¨
Snow caving
¨
Other ______________
¨
Fishing
¨
Orienteering/Rogaining
¨
Snorkelling
Activity Duration*
Number of people involved*
Was this an EOTC incident?
YES
NO
_____ Participants e.g. students
_
Curriculum area (schools only)
______ Volunteer helpers e.g. parent help
______ Hours
¨
English
¨
Technology
¨
Languages
¨
Social Sciences
______ Qualified instructors
e.g. 3 1/2 days = 84 hours
¨
Mathematics
¨
Arts
______ Supervisors e.g. teachers, youth leaders
¨
Science
¨
Health & PE
4. Activity Leader
(Choose leader most in charge of the group that had the incident)
Was there a leader*?
YES
NO
UNKNOWN
(If no, or unknown, go to 5.)
First name:
Last name:
Does the activity leader have relevant activity qualifications*?
YES
NO
UNKNOWN
Age*: ______
Gender*:
M
F
Leader’s experience
level*:
1
2
3
4
5
6
UNKNOWN
UNKNOWN
UNKNOWN
(1= Inexperienced,- 6 = Highly experienced)
5. Equipment involved in incident
Vehicles, property, gear, equipment damaged, equipment lost, etc.
..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
6. Narrative
(general description of incident - what, where, how)
..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
..................................................................................................................................................................................................
7. Causal Factors
Equipment*
Environment*
People*
Activity Leader/s
Participant/s
¨
No equipment
¨
Adverse weather
¨
Inadequate physical condition
¨
Inadequate physical condition
¨
Wrong equipment
¨
Inadequate visibility/dark
¨
Inadequate mental condition
¨
Inadequate mental condition
¨
Faulty equipment
¨
Terrain
¨
Inadequate emotional condition
¨
Inadequate emotional condition
¨
Inadequate design
¨
Water
¨
Inadequate health – hygiene or
¨
Inadequate health – hygiene or
¨
Other __________
¨
Animal/insect/plant
medical
medical
¨
n/a
¨
Other __________
¨
Pre-existing condition
¨
Pre-existing condition
¨
n/a
¨
Judgement error
¨
Judgement error
¨
Inadequate supervision
¨
Inadequate supervision
¨
Inadequate training/experience
¨
Inadequate training/experience
¨
Failure to follow policies
¨
Failure to follow policies
¨
Improper motivation
¨
Improper motivation
¨
Other __________
¨
Other __________
¨
n/a
¨
n/a
Explain in detail what you think caused the incident. Include any suggestions, observations or recommendations regarding the incident.
..................................................................................................................................................................................................
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Hand form into your organisation’s administrator for input to the National Incident Database – Thank you.
www.incidentreport.org.nz
For further copies go to

Download Outdoor Education Incident Report Form - New Zealand

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