Middlebury College Snowbowl/Rikert Incident Report

INCIDENT REPORT

MIDDLEBURY COLLEGE SNOW BOWL
SHORT FORM?

YES
No major intervention, example: applying bandaids
DATE:

MonthDayYear
HourMinutesAM/PM Option
- NAME:
- ADDRESS:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- ^{Note: Should reflect most permanent address}
- TELEPHONE:
  personal phone if over 18, parent/guardian number if younger than 18
- EMAIL:
  personal phone if over 18, parent/guardian number if younger than 18
- DOB:
- AGE:
- HEIGHT:
- WEIGHT:
- GENDER IDENTITY:
  
  MALEFEMALEOther
- TYPE:
  
  ALPINE SKIERBOARDERNORDIC SKIERSNOW SHOERBIKEROther
- Other Examples may include Racer, Student, Tele, Etc
- TRAIL NAME:
- SPECIFIC LOCATION:
- VENUE:
  
  SNOW BOWLRIKERT
- DIFFICULTY:
  
  EASIERMORE DIFFICULTMOST DIFFICULT
- Adjust difficulty given specific location
- LEVEL:
  
  BEGINNERINTERMEDIATEADVANCED
- INCIDENT OCCUR DURING LESSONS:
  
  YESNO
- INSTRUCTOR:
- # OF RUNS TODAY:
- SKIED THIS RUN BEFORE?
  
  YESNO
- EQUIPMENT:
  
  RENTAL - SNOW BOWLOWNED/OTHER
- PRIOR INJURY:
  
  YESNO
- DESCRIBE INJURY:
- YEAR INJURED:
- CORRECTIVE LENSES:
  
  YESNO
- WORN:
  
  YESNO
- MEDS TAKEN:
  
  YESNO
- WHAT?
- WHEN?
- ALLERGIES:
  
  YESNO
- DESCRIBE
- SKIER'S DESCRIPTION
  One to three sentences in quotations
- EQUIPMENT REMOVED BY:
  
  FALLINJUREDPATROLOTHER
- SIDE:
  
  RIGHTLEFT
- INJURY:
- HELMET:
  
  YESNO
- SIGNATURE:
- PARENT/ GUARDIAN:
- PARENT/ GUARDIAN NAME:
- TRANSPORT BY:
  
  PATROLWALK INOTHER
- TREATMENT ON HILL:
- ATTENDING PATROLLERS ON HILL:
- TREATMENT IN HUT:
- ATTENDING PATROLLERS IN HUT:
- LEFT BY:
  
  MREMSCARWALK OUT
- DESTINATION:
  
  HOMERETURN SKIINGOther
- SNOW TYPE:
  
  POWDERPACKED POWDERFROZEN GRANULAROther
- WEATHER:
  
  FOGSNOWOVERCASTRAINCLEAR
- TEMPERATURE:
  
  BELOW 00-32 DEGREESABOVE 32
- WIND:
  
  CALMMODERATEHIGH
- FIRST WITNESS
- NAME:
- PHONE:
- ADDRESS:
  
  ADDRESS
  
  Street Address Line 2
  
  CITYSTATE
  
  ZIP
- ADD ANOTHER
- SECOND WITNESS
- NAME:
- PHONE:
- ADDRESS:
  
  ADDRESS
  
  Street Address Line 2
  
  CITYSTATE
  
  ZIP
- COMMENTS:
- Pertinent incident scene info, Subjective/Objective patient info., advice given for short term care.
- SIGNATURE:
  
  Of Patroller Filling out Form
- PATROLLER:
- VENUE:
  
  SNOW BOWLRIKERT
- NAME OF INJURED:
- INJURY:
- PATROLLER:

INCIDENT REPORT

INCIDENT REPORT