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* MM slash DD slash YYYY Name of person completing this report:* First Last Date of Incident* MM slash DD slash YYYY Time of Incident Hours : Minutes AM PM AM/PM The Incident Happened...* At a Venture Outdoors EventAt a Kayak Pittsburgh LocationOn a Venture Outdoors Adult TripOn a Youth or College Trip/ActivityOther - please elaborate in the next section"Other" more detailsIf "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*StaffInternVolunteerPhone*Please enter the best phone number where we can contact youEmail*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*SunnyWindyCloudyRainyRainy - ThunderstormsSnowyN/A - IndoorsSeverity of weather*MildModerateSevereDescribe 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. Near MissSlightModerateSevereWas this a BEHAVIORAL related incident or NON-BEHAVIORAL related incident?*Behavioral = behaviors that are repetitive and escalate beyond basic management strategies, bullying, fighting, etc. Behavioral NON-Behavioral Behavior (choose one or more)* Excessive Touching/Personal Space violation Insubordination (not following direction, refusal, talking back) Destruction of property Stealing Name-calling, teasing, isolation Profanity Out of bounds (leaving the property) Verbal aggression Physical aggression (hurting self/kicking furniture, shoving Fighting Bullying Lying/dishonesty Other Time it took to resolve the behavior*# of staff minutes spent away from the groupPlease 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 hereWas the press alerted or involved?* Yes No If yes - who was alerted/involved and by whom?Final comments/notes
