incidentreport - Venture Outdoors

Venture Outdoors Incident/Near Miss Report

Please complete the following within 24 hours of the incident. If needed, use the last comments field to fully answer the questions. Have questions about this form? Please check out these FAQs: https://bit.ly/2VZ8zvT

Today's Date*
Date Format: MM slash DD slash YYYY
Name of person completing this report:*
First Last
Date of Incident*
Date Format: MM slash DD slash YYYY
Time of Incident

HH :

MM
The Incident Happened...*
"Other" more details
If "Other" was chosen in the previous question, please elaborate here.
Location of the Incident:*
Did this incident happen at one of the Kayak Pittsburgh locations? Please specify below.
- Yes
- No
Specific Location:*
Please state the specific location where the incident took place.
Your Role within Venture Outdoors/Kayak Pittsburgh*
Phone*
Please enter the best phone number where we can contact you
Email*
Please enter the best email where we can contact you
Full name(s) of other person(s) present:*
Full name(s) of participant(s) involved in the incident:*
Type of weather during incident*
Severity of weather*
Describe the Incident:*
Only the facts - cause, type of injury/illness/damage that resulted, any further notes on the weather/conditions.
How serious did this incident appear to you?*
NEAR MISS = an unplanned event that did not result in injury, illness, or damage - but had the potential to do so.
SLIGHT = participant not evacuated or taken to hospital; first aid may have been used.
MODERATE = participant evacuated or taken to hospital; first aid was required.
SEVERE = required evacuation, hospitalization; potential long-term consequences to persons or property.
What actions were taken at the time by Trip Leaders/Staff/Site Supervisors?*
Were the local authorities (police, fire, EMS, park rangers) alerted or involved?*
- Yes
- No
If yes - please add more details here
Was the press alerted or involved?*
- Yes
- No
If yes - who was alerted/involved and by whom?
Final comments/notes