Prescott College Incident Report Form

Prescott College Incident Report Form
Organization*
e.g., Prescott College
Program Type*
e.g., adventure education, environmental education, intercultural program, service
Course or Activity Name*
Patient/Subject Full Name*
(One Name Per Form)
Did incident take place during Wilderness Orientation?*

YesNo
Did incident take place at one of the PC Field Stations?

Kino Bay CenterDopoi Center
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.*

FatalityInjuryPsychosocial = behavioral, emotional, motivational, or mental healthInclusion = incident of any type made more severe because of attitudes or behaviors that are not inclusive.IllnessNear Miss;Personal Security RiskOther
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;Head Injury (Change in LOC);Eye Injury;Fracture;Frostbite;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 Injury. Please explain.
If Injury: Anatomical Location of Injury. Choose most appropriate.

Abdomen;FingersShoulder;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 - 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
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/alpine);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.
Did this incident involve a pre-existing injury(s) and/or condition(s)?*
If answered yes, please describe:
Please select the PRIMARY Contributing Factor
Please select the SECOND Contributing Factor
Please select the THIRD Contributing Factor
Were there additional Contributing Factors?*
Please list any other Contributing Factors

AltitudeWeatherAvalancheCold ExposureAnimal EncounterVisibilityLoose RockFalling tree/branchPlant poisoning/toxicity/contactTechniqueEquipmentTechnical systems failureInattentionCarelessnessExhaustionDehydrationFitness/abilityExceeded AbilityFall on rockRock fallFall on snowFall/Slip on trailSunburnImmersion/submersionOveruse injuryMissing/LostPreexisting medical conditionPre-existing psychological or mental health issueHygieneScreeningSupervisionInstructionNot following instructionsMisbehaviorInterpersonal conflictGroup DynamicsBullyingLack of belonging/InclusionDiscriminationBehavioralMotivationalUnknownOther
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 E-mail
Preparer's Signature

Clear
Preparer Signature Date

MonthDayYear
Field Risk Manager/Field Risk Committee Review

Faculty + Instructors, please DO NOT fill out the next section.
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:

Prescott College Incident Report Form

Field Risk Manager/Field Risk Committee Review