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.*

InjuryIllnessPsychosocial: Behavioral, Emotional, Motivational, or Mental Health IncidentNear Miss;Personal Security RiskFatalityBelonging or Inclusion relatedOther
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
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.
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
Narrative: Describe the incident and provide details - including distances - times - sizes -sequence of events - etc. to present a clear picture of the incident.*
Analysis: Include any suggestions - observations or recommendations regarding the incident. Why did it happen? Follow up care and any diagnosis or other outcome.*
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
Reviewed by:

First NameLast Name
Reviewer Position:
Reviewer Signature

Clear
Reviewer Signature Date

MonthDayYear
Should be Empty: