"Incident Report Form - Tablelands Walking Club Inc"

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Incident Report Form
To be completed by activity organizers/walk leaders as soon as practical after the
incident. This report should be kept by the club secretary as a formal club record. In the
event of any serious injury (an injury requiring medical treatment) copies of the incident
report must be forwarded to the Insurance Convener for the State of the Member Club.
Provide relevant information and mark the appropriate option(s).
Trip information
Date _________________ Time ______________ Destination _________________________________
Leader __________________________________________________________
Trip Contact Officer __________________________________Phone No. _______________________
Number of Walkers ______________ Experienced ____________ Intermediate ______________
Inexperienced ____________
Type of incident
Delay Lost party members Fall Injury Snakebite Insect bite Illness Fatigue Hyperthermia
Hypothermia
Additional Information _________________________________________________________________
____________________________________________________________________________________
Witnesses _______________________________________________________________________________
__________________________________________________________________________________________
Location of incident
Map ____________________ Datum ____________ Map Coordinates _________________________
Elevation _________m Lat & Long (GPS) _________________________________________________
Terrain Open Closed canopy Water course Slippery Rocky Steep Ridge Gorge
General Description ____________________________________________________________________
__________________________________________________________________________________________
Weather Hot Warm Cool Cold Sunny Windy Foggy Cloudy Rain
Other____________________________________________________________________________________
First Aid Assessment Overall condition Good Fair Poor Serious Critical
Primary Injury/Situation _______________________________________________________________
__________________________________________ _______________________________________________
Secondary Injury(s) _____________________________________________________________________
__________________________________________ _______________________________________________
Incident Report Form
To be completed by activity organizers/walk leaders as soon as practical after the
incident. This report should be kept by the club secretary as a formal club record. In the
event of any serious injury (an injury requiring medical treatment) copies of the incident
report must be forwarded to the Insurance Convener for the State of the Member Club.
Provide relevant information and mark the appropriate option(s).
Trip information
Date _________________ Time ______________ Destination _________________________________
Leader __________________________________________________________
Trip Contact Officer __________________________________Phone No. _______________________
Number of Walkers ______________ Experienced ____________ Intermediate ______________
Inexperienced ____________
Type of incident
Delay Lost party members Fall Injury Snakebite Insect bite Illness Fatigue Hyperthermia
Hypothermia
Additional Information _________________________________________________________________
____________________________________________________________________________________
Witnesses _______________________________________________________________________________
__________________________________________________________________________________________
Location of incident
Map ____________________ Datum ____________ Map Coordinates _________________________
Elevation _________m Lat & Long (GPS) _________________________________________________
Terrain Open Closed canopy Water course Slippery Rocky Steep Ridge Gorge
General Description ____________________________________________________________________
__________________________________________________________________________________________
Weather Hot Warm Cool Cold Sunny Windy Foggy Cloudy Rain
Other____________________________________________________________________________________
First Aid Assessment Overall condition Good Fair Poor Serious Critical
Primary Injury/Situation _______________________________________________________________
__________________________________________ _______________________________________________
Secondary Injury(s) _____________________________________________________________________
__________________________________________ _______________________________________________
Patient Male Female
Name_______________________
Address
_________________________________
_________________________________
______________
Who to Notify
_________________________
Contact Phone No(s)
____________________
Action taken
Search First Aid DRABC
Pressure Bandage CPR
Warming Cooling Party Sent
for Assistance
Additional Information__________________________________________________________________
__________________________________________________________________________________________
Assistance Required (Specify qualifications and numbers of helpers or teams required)
Personnel Paramedic Doctor Search Rescue/Recovery
Medication Water Food Shelter
Other ________________________________________________________
Communications Available (e.g. Mobile No. / CB channel) _____________________________
For emergencies, dial 112 from a mobile phone, or 000 from a landline.
Time of call: _____________
Planned Action (If moving give Route and Map Coordinates of destination) Remain at site
Evacuate to Track Road Track Junction Shelter Natural Feature Helipad
Additional Information ________________________________________________________________
Evacuation Plan / Requirements Walk out Improvised Stretcher Stretcher Ambulance Helicopter
Winch Helipad
Additional Information_________________________________________________________________
__________________________________________________________________________________________
This form is intended to help your decision-making in a stressful situation, provide essential
information to those called upon to assist, and record details for insurance claims. Send one copy of the
information with any party sent out for help. Keep one and continue to record relevant information.
(For example, log observations of the patient’s vital signs, times of events, actions and communications, details
of parties sent out, self-sufficiency of the party - equipment, physical and psychological condition of members)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Forward a copy to the Safety & Training Officer or another Committee Member as soon as
possible
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