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?
Did incident take place at one of the PC Field Stations?
Age
Gender
Role
Incident Date

MonthDayYear
Hour MinutesAM/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.

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
Other Property Damage:
If Injury: Type of Injury. Choose the most significant.
Other Injury. Please explain.
If Injury: Anatomical Location of Injury. Choose most appropriate.

Other
If Illness: Type of Illness. Choose most significant.
Other Illness. Please explain.
If Psychosocial - Behavioral, Emotional, Motivational, or Mental Health Incident- Choose most significant.

Other
If Inclusion or Belonging Related - Choose most significant.

Other
Type of Activity. Check the activity at the time of the incident
Other Activity. Please explain.
Did this incident involve a pre-existing injury(s) and/or condition(s)?
If answered yes, please describe:
Contributing Factors
Please select the PRIMARY Contributing Factor
Please select the SECOND Contributing Factor if applicable
Please select the THIRD Contributing Factor if applicable
Were there additional Contributing Factors?
Please list any other Contributing Factors

Other
Details
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.

Cancelof
Prepared By:

First NameLast Name
Preparer's Position:
Preparer E-mail
example@example.com
Preparer's Signature
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
Reviewer Signature Date

MonthDayYear
Should be Empty:

Prescott College Incident Report Form

Contributing Factors

Details

Field Risk Manager/Field Risk Committee Review