Incident Report Form

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Incident Report Form

Club - Illawarra Ramblers Club.
Activity
Leaders Name
First Last
Name of Injured Person
First Last
Gender
- Male
- Female
Age
Date of Incident
Date Format: DD slash MM slash YYYY
Time of Incident
Location of Incident
Map used / details
Grid References
Weather at time of incident
How did the incident happen?
What were the injuries?
What first aid was administered?
Where did the casualty go to receive medical aid?
What time was medical aid received?
Doctor Name
First Last
Witness 1 Name
First Last
Witness 1 Phone Number
Witness 2 Name
First Last
Witness 2 Phone Number