incidentreport - Venture Outdoors

Today's Date*

Name of person completing this report:*

First Last

Date of Incident*

Time of Incident

:

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?*

GOOD CATCH! = something you observed or an action taken that helped prevent an incident
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.

Was this an EXCLUSIONARY incident?*

Exclusionary incidents include targeted incidents t hat cause people to feel unwelcomed (ex: raciest/ageist comments, unwelcoming green spaces, etc.)

Yes, this was an EXCLUSIONARY incident
No, this was not an exclusionary incident

Was this a BEHAVIORAL related incident or NON-BEHAVIORAL related incident?*

Behavioral = behaviors that are repetitive and escalate beyond basic management strategies, such as bullying, fighting, etc.

Behavioral
NON-Behavioral

Behavior (choose one or more)*

Time it took to resolve the behavior*

# of staff minutes spent away from the group

Please enter a number from 0 to 240.

Did you speak with a parent/guardian?*

If "yes", outline which parents you spoke to and what was discussed in the next question below.

Yes
No

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

Venture Outdoors Incident/Near Miss Report