PBC Safety Incident Form
This form should be completed as soon as possible after the incident. If you have additional diagrams or photos you wish to include in the report please email these separately to PbClubSafety@gmail.com. If you prefer a word document version of this form to fill in please email us.
1. Details of Person reporting incident
Your Name
First Name
Last Name
Your role at the time of the incident
Skipper
Crew
Witness
Other
Your e-mail
*
Your contact number
-
Area Code
Phone Number
Your address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Details of Person(s) Involved in Incident
Please add person(s) names Involved in incident
Details of Boat Involved
Date of Incident
-
Month
-
Day
Year
Date
Time of Incident
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Location of Incident
2. Environmental Conditions
Visibility
Good
Fair
Poor
State of Water
Calm (Glassy)
Calm (rippled 0-0.25m waves)
Smooth (0.25m-0.5m waves)
Slight (0.5m-1m waves)
Moderate (1m-2m waves)
Rough (2-4m waves)
Very rough (over 4m waves)
Wind Force
None
Light (4-10 knots)
Moderate (11-27 knots)
Near Gale (28-33 knots)
Gale (34-39 knots)
String Gale (40+ knots)
Other factors
Sun strike
Fog
Rain
Hail or Sleet
Dark
Change of Light
Strong Tidal flow
3. What Happened
Select any that apply
Petrol or other harmful sunstance spill
Flip/ Overturn
Person Overboard
Collision
Flooded
Propeller Entangled
Contact (Impact)
Propulsion Failure
Electrical Power Failure
Grounding
Hit Submerged Object
Steering Gear Failure
Entrapment
Structural Failure
Equipment Failure
Explosion
Near Miss / Close Quarters
Other (Please explain below)
Other Incident type
Was another boat/craft involved
Yes
No
Name (If known)
Type and distinguishing characteristics
Description of Incident
If you need to write more, or wish to add a diagram with details of what happened, please email additional information to the email addresses at the top of this form
4. Injury Information
Add details of injured persons below (if any)
Injury details person 1
Injury information for Person 1
Injury Person 1
Treatment Person 1
Treatment source
First Aid
Ambulance
Doctor (GP)
Hospital
Other
Injury details person 2
Injury information for Person 2
Injury Person 2
Treatment Person 2
Treatment source person 2
First Aid
Ambulance
Doctor (GP)
Hospital
Other
Injury details person 3
Injury information for Person 3
Injury Person 3
Treatment Person 3
Treatment source person 3
First Aid
Ambulance
Doctor (GP)
Hospital
Other
Declaration - The above report provides a true and accurate account of the incident.
Safety Officers Review
What were the causative factors of this incident
How can this incident be prevented from happening again
Addition details or information
Action Summary
New Hazard Identified?
Yes
No
Significant Hazard?
Yes
No
Changes to SMS made?
Yes
No
Changes communicated?
Yes
No
Has regulator been notified?
Yes
No
Further Investigation required?
Yes
No
Hazard has been
Eliminated
Isolated
Minimised
Declaration
Report Completed By
Save
Submit
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