Kino Bay Center - Incident Report Form

Organization

Please put in the name of your institution or organization if applicable

Program Type

Course/Trip/Activity Name

Did incident take place in Kino Bay?

Name of Patient/Subject of Incident

First NameLast Name

Age

Gender

Role

Incident Date

MonthDayYearHourMinutesAM/PM Option

Total Days of Course

Day Incident Occurred

Type of Environment. Check all that apply.

Surface Condition. Check the two most signifcant.

Type of incident. Check most significant.

Is this a Lost-Day case?

Number of days lost:

Did the individual leave the field?

Date individual left field:

MonthDayYear

Evacuation Method:

Please enter evacuation method:

Did the individual visit a medical facility?

Medical Facility Admission Status:

Did the individual return to the course?

Date Returned to Course

MonthDayYear

Property Damage?

Property Damage Type

Other Property Damage:

If Injury: Type of Injury. Choose the most significant.

Other Inury. Please explain.

If Injury: Anatomical Location of Injury. Choose most appropriate.

If Illness: Type of Illness. Choose most significant.

Other Illness. Please explain.

If Psychosocial - Behavioral, Emotional, Motivational, or Mental Health Incident- Choose most significant.

If Inclusion or Belonging Related: Please choose the type of Inclusion or Belonging Related Incident. Choose most significant.

Did this incident involve a pre-existing injury(s) and/or condition(s)?

If answered yes, please describe:

Type of Activity. Check the activity at the time of the incident

Other Activity. Please explain.

TIMELINE & DETAILS OF INCIDENT: Provide a detailed timeline of the incident. Use this format: Date + Time + Description. Please include specifics (e.g., sequence of events, who was involved and when, distances, locations, weather, times, sizes, etc.). Please present an OBJECTIVE timeline of the incident. You can include in the timeline follow-up care details, diagnosis, or other outcomes.

Please Upload ALL Files Related to Incident - SOAP Notes, Student Support Plans, Photos of WO Course Log, Behavioral Contracts, No-Harm Contracts, etc.

Upload a File

Prepared By:

First NameLast Name

Preparer's Position:

Preparer's Signature

Preparer Signature Date

MonthDayYear

Preparer Email

ACTION STEPS - AS NEEDED: TO BE COMPLETED BY FIELD RISK MANAGER OR FIELD RISK COMMITTEE REVIEWER/EXTERNAL REVIEWER ONLY. If necessary, please outline any action steps to be taken based on a review of the incident.

Reviewed by:

First NameLast Name

Reviewer Position:

Reviewer Signature

Reviewer Signature Date

MonthDayYear