Incident Report Form

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Club: Illawarra Ramblers Inc.

Reported by*
This can be the person affected, the leader or a participant who witnessed the incident
First name Last name
Phone no.*
Activity*
e.g. Mount Keira ring track
Grade of activity
(if known)
Please enter a number from 1 to 5.
Type of activity*
- Walk
- Cycle
- Paddle
Leader's name*
First name Last name
Name of injured person*
First name Last name
Address of injured person
(if known)
Phone no. of injured person
Date of incident*
DD slash MM slash YYYY
Time of incident

: Hours

Minutes

AM/PM
Weather conditions
Location of incident*
Type of incident or injury*
Incident details*
External involvement
e.g. authorities or other agencies notified
Witness 1
First name Last name
Phone
Witness 2
First name Last name
Phone
Supplementary information
e.g attachments

Illawarra Ramblers Club