Middlebury College Snow Bowl Incident Report

INCIDENT REPORT

MIDDLEBURY COLLEGE SNOW BOWL
SHORT FORM?

YES
No major intervention, example: applying bandaids
DATE:

Month Day Year
Hour Minutes AM/PM Option

INJURED PERSON
NAME:
ADDRESS:

Street Address

Street Address Line 2

City State / 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:

MALE FEMALE
TYPE:

ALPINE SKIER BOARDER NORDIC SKIER SNOW SHOER BIKER
Other Examples may include Racer, Student, Tele, Etc

LOCATION
TRAIL NAME:
SPECIFIC LOCATION:
VENUE:

SNOW BOWL RIKERT
DIFFICULTY:

EASIER MORE DIFFICULT MOST DIFFICULT
Adjust difficulty given specific location

SKIING HISTORY
LEVEL:

BEGINNER INTERMEDIATE ADVANCED
INCIDENT OCCUR DURING LESSONS:

YES NO
INSTRUCTOR:
# OF RUNS TODAY:
SKIED THIS RUN BEFORE?

YES NO
EQUIPMENT:

RENTAL - SNOW BOWL OWNED/OTHER

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

FALL INJURED PATROL OTHER

INJURY AREA & PROBABLE TYPE
SIDE:

RIGHT LEFT
INJURY:
HELMET:

YES NO

SIGNATURE
SIGNATURE:

Clear
PARENT/ GUARDIAN:

Clear
PARENT/ GUARDIAN NAME:

FIRST AID & PATROLLERS ATTENDING
TRANSPORT BY:

PATROL WALK IN OTHER
TREATMENT ON HILL:
ATTENDING PATROLLERS ON HILL:
TREATMENT IN HUT:
ATTENDING PATROLLERS IN HUT:
LEFT BY:

MREMS CAR WALK OUT
DESTINATION:

HOME RETURN SKIING

WITNESSES
FIRST WITNESS
NAME:
PHONE:
ADDRESS:

ADDRESS

Street Address Line 2

CITY STATE

ZIP
ADD ANOTHER
SECOND WITNESS
NAME:
PHONE:
ADDRESS:

ADDRESS

Street Address Line 2

CITY STATE

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 BOWL RIKERT
NAME OF INJURED:
INJURY:
PATROLLER: