SSS Participant Incident Report Form

SSS Accident Report - Participant

Killington/Pico Ski Resort Partners, LLC
DATE OF INCIDENT

MonthDayYear
Date
Time of Incident

Hour Minutes

AM/PM Option
SPECIFIC LOCATION OF INCIDENT
PARTICIPANT'S NAME
PARTICIPANT'S AGE
Participant Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Equipment Type

Other
Equipment Ownership
If Equipment was rented, please capture
Rental Number: blank
DIN: blank
Location (Killington or Pico)
Lesson Type
Class Level
Number of participants in class
Single or Multi Day Lesson?
Number of days with Instructor
Describe participant's ability level at time of incident
At what point in class progression did incident occur?
Describe how the incident occurred
How far were you from participant at time of incident?
Distance in Feet
Describe Location relevant to Participant
Describe your actions before, during and after the incident
Participant was
If "other" describe
Did Participant continue to ski or ride after incident?
Did you witness the incident
Did anyone make statements to you about the incident
If yes, who?
Describe Statements
Was the incident the result of a collision with another individual
Name of other party involved in the collision
If lift was involved, name of lift
Were you in the same chair as Participant
What seat was Participant in
What seat were you in relative to Participant
If you weren't in same chair as participant, what chair were you in?
Number of times Participant has ridden this lift on the day of incident
Number of times Participant has ridden this lift prior to incident
Number of times Participant has ridden other lifts
Other lift passenger's names
Witnesses and/or other Participants in class
Witness #1
Name and Contact Information
Witness #2
Name and Contact Information
Witness #3
Name and Contact Information
Witness #4
Name and Contact Information
Please continue to record additional wintess and/or class participants names and contact information here.
Follow up information and additional remarks
INSTRUCTOR PRINT NAME
INSTRUCTOR'S SIGNATURE
DATE

MonthDayYear
Date
SUPERVISOR PRINT NAME
SUPERVISOR'S SIGNATURE
DATE

MonthDayYear
Date
Should be Empty:

Witnesses and/or other Participants in class