WILDERNESS RISK MANAGERS INCIDENT REPORT

Program/Course Name 		

Program Type		

# Staff		# Participants		# Program Days	

Name  		(circle) Male/Female 

Staff/Student	Age 	

Incident Date 	 	 Time       :        AM/PM  Day of course incident occurred	

Geographical Location of Incident 		
		
WEATHER at Time of Incident: 
Temp (°F) 	   Precipitation (circle) Rain or Snow  or None
Wind (mph)		Visibility	 (ft or miles)
Surface Condition(circle)  wet   dry   snow   ice   trail   rock   uneven   flat   sloped

TYPE OF INCIDENT: Check each applicable category:

Injury		Illness		Motivation/Behavior		Near Miss 	

Is this a Lost-Day case?		NO 	YES	If Yes, # of Days Lost	

Did the victim leave the field?		NO 	YES	If Yes, on what date	

Evacuation method (circle) walk unassisted, litter, vehicle, helicopter, other	

Did the victim visit a medical facility?		NO 	YES	If Yes, length of stay in days	

Did the victim return to the course?		NO 	YES	If Yes, on what date	

Was there damage to (circle) vehicle, equipment or property?
		
TYPE OF INJURY  (check all that apply)
	bruise, contusion or similar soft-tissue trauma		immersion foot
	ligament sprain		tendinitis
	muscle strain		eye injury
	frostbite		dental or tooth-related
	fracture		burn
	dislocation		blister(s)
	head injury without loss of consciousness		laceration
	head injury with loss of consciousness		skin abrasions
	near drowning or other submersion problem		sunburn 
	other 	

ANATOMICAL LOCATION OF INJURY
	Head		Forearm		Pelvis
	Face		Wrist		Hip
	Eye		Hand/Fingers		Thigh
	Neck		Chest		Knee
	Shoulder		Abdomen		Lower Leg
	Upper Arm		Upper Back		Foot
	Elbow		Lower back		Ankle
					Toe

TYPE OF ILLNESS  (check all that apply)
	allergic reaction	
		mild or localized	
		severe, generalized or anaphylaxis	
	altitude illness	
		acute mountain sickness	
		pulmonary edema	
		cerebral edema
	hypothermia (specify core temperature if known     oF/    oC
	heat illness(specify core temperature if known       oF/    oC
		heat exhaustion	
		heat cramps	
		heat stroke	
	chest pain or cardiac condition	
	upper respiratory illness (runny nose, congestion, “cold")
	upper respiratory illness (other)	
	abdominal or other gastrointestinal problem without diarrhea	
	diarrhea
	apparent food-related illness
	nonspecific fever illness
	urinary tract infection
	skin infection
	eye infection
	other		

PROGRAM ACTIVITY (activity at the time of the incident)
	Backpacking 		Horse 		Ropes course		Snow Climb
	Camp		Initiative Game		Rock climbing		Snowshoeing
	Canoe		Kayak		Run		Solo
	Caving		Mountaineering		Sail		Sportyak
	Cooking		Portage		Service		Swim/Dip
	Cycle		Rafting		Ski w pack		Unaccmp. Travel
	Dog sledding		River crossing		Ski w light pack		Urban activity
	Glacier travel		Rappel		Sea Kayak		Vehicle/Van
	Hike no pack		Other(explain)						

IMMEDIATE CAUSE (prioritize major applicable categories 1, 2, 3, etc.)
	Altitude		Immersion/submersion		Poor Technique
	Avalanche		Inexperience/poor judgment		Psychological
	Cold Exposure		Intoxication(alcohol/drugs)		Sunburn
	Carelessness		Inadequate Instruction		Technical ystem 
						Failed
	Dark/poor visibility		Improper Screening		Unfit
	Dehydration		Inadequate Supervision		Unknown
	Inadequate Equipment		Lightning		Weather
	Exceeded ability		Hazardous animal/insect (specify)			
	Exhaustion		Misbehavior	
	Fall/Slip on trail;		Overuse injury		Missing/Lost
	Fall on snow		Poor camp/personal hygiene	
	Fall on rock		Preexist. medical condition	
	Falling rock		Plant poisoning/toxicity	
	Failure to follow instructions	
	Falling tree/branch		Other(explain)				

NARRATIVE:  Describe the incident.  What, how and when it happened, any medical treatment, and the final medical outcome or diagnosis.  

	

	

ANALYSIS:  Include any observations, recommendations or suggestions regarding prevention.

	

	

Report prepared by: 	Position: 	  Date: 	

Signature: 	  Date:		

Patient Report:

Name			
Age	Sex	 
Chief Complaint(PQRST)	
	
Date & Time of Incident	
History of Present Illness/MOI	

Vital Signs (quantity and quality)
Time	LOC	Pulse	RR	BP	To	CRT	SCTM
	Pupils							

								

Physical Findings/Appearance	

	
	
Past History	
Allergies	
Medications	
Medications Administered 	Amount	Date/Time

	

Emergency Care Rendered/Changes in Patient’s Condition	

	
	
Details of Evac Plan(timetable, backup, pickup point)