Middlebury College Snow Bowl Incident Report

INCIDENT REPORT

MIDDLEBURY COLLEGE SNOW BOWL
SHORT FORM?

YES
No major intervention, example: applying bandaids
DATE:

MonthDayYear
HourMinutesAM/PM Option

INJURED PERSON
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:

MALEFEMALE
TYPE:

ALPINE SKIERBOARDERNORDIC SKIERSNOW SHOERBIKER
Other Examples may include Racer, Student, Tele, Etc

LOCATION
TRAIL NAME:
SPECIFIC LOCATION:
VENUE:

SNOW BOWLRIKERT
DIFFICULTY:

EASIERMORE DIFFICULTMOST DIFFICULT
Adjust difficulty given specific location

SKIING HISTORY
LEVEL:

BEGINNERINTERMEDIATEADVANCED
INCIDENT OCCUR DURING LESSONS:

YESNO
INSTRUCTOR:
# OF RUNS TODAY:
SKIED THIS RUN BEFORE?

YESNO
EQUIPMENT:

RENTAL - SNOW BOWLOWNED/OTHER

SKIER'S DESCRIPTION OF INCIDENT
SKIER'S DESCRIPTION
One to three sentences in quotations
EQUIPMENT REMOVED BY:

FALLINJUREDPATROLOTHER

INJURY AREA & PROBABLE TYPE
SIDE:

RIGHTLEFT
INJURY:
HELMET:

YESNO

SIGNATURE
SIGNATURE:

Clear
PARENT/ GUARDIAN:

Clear
PARENT/ GUARDIAN NAME:

FIRST AID & PATROLLERS ATTENDING
TRANSPORT BY:

PATROLWALK INOTHER
TREATMENT ON HILL:
ATTENDING PATROLLERS ON HILL:
TREATMENT IN HUT:
ATTENDING PATROLLERS IN HUT:
LEFT BY:

MREMSCARWALK OUT
DESTINATION:

HOMERETURN SKIING

WITNESSES
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

PATROLLER'S COMMENTS
COMMENTS:
Pertinent incident scene info, Subjective/Objective patient info., advice given for short term care.
SIGNATURE:

Of Patroller Filling out Form Clear
PATROLLER:

Collapse Stop
VENUE:

SNOW BOWLRIKERT
NAME OF INJURED:
INJURY:
PATROLLER: