IWWF Incident Report Form

IWWF INCIDENT REPORT FORM

This form should be completed by the on-site Safety/Club Official or Event Organizer at the time of an Accident, Injury or Other Incident during An IWWF Sanctioned Event.
SANCTIONED EVENT INFORMATION:
Federation/Club/Event Organizer’s Name: Insert name*

Membership #:  Insert number*

Date(s) of Event: From*  To*

Address/Location of Event:

Street Address*   Address Line 2*   City*   State/Country*

  Zip*
Sanctioned Event Type:

Other
Total Number of Pulls / Tows (sets):
Sport Discipline (please indicate applicable discipline):
SUBJECTS INVOLVED (attach additional reports if more than one person was involved):
Name of Person Injured/Involved:

First NameMiddle NameLast Name
Nationality/Country: Country* Federation: Federation
Date of Birth:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Gender:
Email adress:
example@example.com
Home Address:

Street Address

Street Address Line 2

CityState / Province/Country

Postal / Zip Code
Phone Number:

Country CodeArea CodePhone Number
Name of Parent/Legal Guardian (if minor):

First NameMiddle NameLast Name
Phone Number:

Country CodeArea CodePhone Number
Membership Status

Other
Type of Individual:

Other
Waiver Release
Please Attach Signed Waiver Release Form

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Note: Signed waivers are required for all participants in sanctioned events
DESCRIPTION OF ACCIDENT/INCIDENT/INJURY/ILLNESS (check all that apply):
Type of Incident:

Other
Incident Location:

Other
Weather:

Other
Water Conditions
Wind Conditions
Date and Time of Incident (12h time format - AM/PM)

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Hour MinutesAM/PM Option
Incident during Sanctioned Event?
Type of Event during which Incident/Injury occurred: Please specify*
Please answer the questions below and make use of the text blocks provided on this form to document additional details of this incident.
Safety Director on-site during the Event:
Were proper safety procedures and equipment utilized?
Were proper safety procedures and equipment utilized?
Name of Boat Driver

First NameLast Name
Does the driver of the boat have an IWWF / National driver rating?
If so, what rating? Please specify
Police, DNR or Fire Department Notified:
Explain (autosizing text box, unlimited characters :
Any Witnesses to Incident/Injury:
- Name

First NameLast Name
Phone Number

Country CodeArea CodePhone Number
- Name

First NameLast Name
Phone Number

Country CodeArea CodePhone Number
First Aid Treatment rendered on-site:
Explain (autosizing text box, unlimited characters) :
Primary Medical Insurance Available:
If yes, Carrier and Policy #:
Photographs of Injury/Damage:
If yes, please attach to this form

Accepted formats: pdf, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
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REPORT PREPARED BY:
Name of Safety/Club Official or Event Organizer:

First NameMiddle NameLast Name
Phone Number

Country CodeArea CodePhone Number
Email address
example@example.com
ADDITIONAL DETAILS OF ACCIDENT/INCIDENT/INJURY/ILLNESS:

(Note - text boxes below are auto-fitting and unlimited)
How did incident/injury occur? (Be specific - not simply “crash on jump")
Location and nature of injury or damage? (Describe as accurately as possible)
FIRST AID TREATMENT AND DISPOSITION:
First Aid Treatment rendered on-site:
Describe :
Was First Aid Treatment Refused? (Note signature requirements below if treatment refused)
Name AND Signature of INJURED PARTY

Name and Signature of injured party
Name AND Signature of WITNESS

(Note: If Witness is a minor, obtain signature of the minor’s Parent/Guardian
First Aid Disposition? (Check all that apply):
Method of Transport to Hospital or Other Medical Care Facility?

Other
Name, Address and Telephone Number of Hospital or Other Medical Care Facility where transported?
Name of Hospital or Facility: Please specify
Address

Street Address

Street Address Line 2

CityState / Province/Country

Postal / Zip Code
Phone Number

Country CodeArea CodePhone Number
Should be Empty:

IWWF INCIDENT REPORT FORM