Kino Bay Center - Incident Report Form

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?*

YesNo
Name of Patient/Subject of Incident

First NameLast Name
Age*
Gender
Role

Staff;Student / Client;
Incident Date

MonthDayYearHourMinutesAM/PM Option
Total Days of Course
Day Incident Occurred
Type of Environment. Check all that apply.*

River;Lake;Ocean;Forest;Mountain;Cliff;Glacier;Snow/Ice;Desert;Cold Environment;N/A;
Surface Condition. Check the two most signifcant.*

Wet;Dry;Snow;Ice;Trail;Rock;Uneven;Flat;Sloped;N/A
Type of incident. Check most significant.*

InjuryFatalityPsychosocial = behavioral, emotional, motivational, or mental healthInclusion = incident of any type made more severe because of attitudes or behaviors that are not inclusive.IllnessPersonal Security RiskNear Miss;Other
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*

Vehicle;Equipment;Other;
Other Property Damage:*
If Injury: Type of Injury. Choose the most significant.

Blister(s);Burn;Dental;Dislocation;Eye Injury;Fracture;Frostbite;Head Injury (Change in LOC);Head Injury (No change in LOC);Immersion foot;Ligament Sprain;Muscle strain;Near drowning or immersion;Soft tissue (bruise wound - abrasion);Sunburn;Tendonits;Other (explain);
Other Inury. Please explain.
If Injury: Anatomical Location of Injury. Choose most appropriate.*

Abdomen;Head/Fingers;Shoulder;Ankle;Head;Thigh;Chest;Hip;Toe;Elbow;Knee;Upper Arm;Eye;Lower Back;Upper Back;Face;Lower Leg;Wrist;Foot;Neck;Forearm;Pelvis;Other
If Illness: Type of Illness. Choose most significant.

Abdominal pain;Heat illness;Allergic reaction;Altitude illness;Nausea or vomiting;Apparent food-related illness;Nonspecific fever illness;Chese pain or cardiac condition;Skin infection;Dehydration;Upper respiratory illness;Diarrhea;Urinary Tract Infection;Eye or ear infection;Flu syymptoms/"cold";Other;
Other Illness. Please explain.
If Psychosocial - Behavioral, Emotional, Motivational, or Mental Health Incident- Choose most significant.

Suicidal IdeationSuicide AttemptEmotional or Psychological DistressAnxietyPTSDDepressionDisordered EatingSelf-Harm/Attempted Self-HarmHarm of Others/Attempted Harm of OthersManic or Depressive EpisodesAggressive BehaviorLow motivation/Request to leaveDiscriminationOther Mental Health Related IncidentOther student conduct issueOther
If Inclusion or Belonging Related: Please choose the type of Inclusion or Belonging Related Incident. Choose most significant.

BullyingGender-based, race-based, and/or other form of discriminationSexual HarassmentLack of Belonging or InclusionSelf-IsolationGroup conflict/group dynamic related issueInterpersonal conflictOther
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*

Backpacking;Initiative game;Sea Kayaking;Camping;Mountaineering;Service project;Canoeing;Portage;Ski (telemark/downhill);Caving;Rafting;Ski touring;Cooking;Rappelling;Snowboarding;Cycling;River crossing;Snow/Ice Climbing;Dog sledding;River kayaking;Snowshoeing;Glacier Travel;Rock climbing;Solo;Hiking (no pack);Ropes Course;Swim/Dip;Horseback Riding;Running;Transportation;Independent Travel;Sailing;Other (explain);
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

Cancelof
Prepared By:

First NameLast Name
Preparer's Position:
Preparer's Signature

Clear
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

Clear
Reviewer Signature Date

MonthDayYear
Should be Empty: