Prescott College Incident Report Form
Organization
*
e.g., Prescott College
Program Type
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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?
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Yes
No
Did incident take place at one of the PC Field Stations?
Kino Bay Center
Dopoi Center
Age
*
Gender
Please Select
Male
Female
Non-Binary
Transgender
Unknown
Role
Staff;
Student / Client;
Incident Date
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Month
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Day
Year
Date Picker Icon
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Hour
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10
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30
40
50
Minutes
AM
PM
AM/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.
*
Injury
Illness
Psychosocial: Behavioral, Emotional, Motivational, or Mental Health Incident
Near Miss;
Personal Security Risk
Fatality
Belonging or Inclusion related
Other
Is this a Lost-Day case?
*
Please Select
Yes
No
Number of days lost:
Did the individual leave the field?
*
Please Select
Yes
No
Date individual left field:
Please select a month
January
February
March
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December
Month
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Year
Evacuation Method:
Please Select
None
Unassisted
Walking Assisted
Litter Carry
Vehicle
Helicopter
Other
Please enter evacuation method:
Did the individual visit a medical facility?
*
Please Select
Yes
No
Medical Facility Admission Status:
Please Select
Outpatient
Admitted
Did the individual return to the course?
*
Please Select
Yes
No
Date Returned to Course
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
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Year
Property Damage?
*
Please Select
Yes
No
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 Ideation
Suicide Attempt
Emotional or Psychological Distress
Anxiety
PTSD
Depression
Disordered Eating
Self-Harm/Attempted Self-Harm
Harm of Others/Attempted Harm of Others
Manic or Depressive Episodes
Aggressive Behavior
Low motivation/Request to leave
Discrimination
Other Mental Health Related Incident
Other student conduct issue
Other
If Inclusion or Belonging Related: Please choose the type of Inclusion or Belonging Related Incident. Choose most significant.
Bullying
Gender-based, race-based, and/or other form of discrimination
Sexual Harassment
Lack of Belonging or Inclusion
Self-Isolation
Group conflict/group dynamic related issue
Interpersonal conflict
Other
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
Altitude
Weather
Avalanche
Cold Exposure
Animal Encounter
Visibility
Loose Rock
Falling tree/branch
Plant poisoning/toxicity/contact
Technique
Equipment
Technical systems failure
Inattention
Carelessness
Exhaustion
Dehydration
Fitness/ability
Exceeded Ability
Fall on rock
Rock fall
Fall on snow
Fall/Slip on trail
Sunburn
Immersion/submersion
Overuse injury
Preexisting medical condition
Missing/Lost
Hygiene
Pre-existing Psychological or Mental Health Issue
Screening
Supervision
Misbehavior
Instruction
Interpersonal conflict
Not following instructions
Group Dynamics
Lack of belonging/inclusion
Bullying
Discrimination/Harassment
Motivational Issue
Behavioral Issue
Unknown
Other - Please Explain
Please select the SECOND Contributing Factor
Please Select
Altitude
Weather
Avalanche
Cold Exposure
Animal Encounter
Visibility
Loose Rock
Falling tree/branch
Plant poisoning/toxicity/contact
Technique
Equipment
Technical systems failure
Inattention
Carelessness
Exhaustion
Dehydration
Fitness/ability
Exceeded Ability
Fall on rock
Rock fall
Fall on snow
Fall/Slip on trail
Sunburn
Immersion/submersion
Overuse injury
Preexisting medical condition
Missing/Lost
Hygiene
Pre-existing Psychological or Mental Health Issue
Screening
Supervision
Misbehavior
Instruction
Interpersonal conflict
Not following instructions
Group Dynamics
Lack of belonging/inclusion
Bullying
Discrimination/Harassment
Motivational Issue
Behavioral Issue
Unknown
Other - Please Explain
Please select the THIRD Contributing Factor
Please Select
Altitude
Weather
Avalanche
Cold Exposure
Animal Encounter
Visibility
Loose Rock
Falling tree/branch
Plant poisoning/toxicity/contact
Technique
Equipment
Technical systems failure
Inattention
Carelessness
Exhaustion
Dehydration
Fitness/ability
Exceeded Ability
Fall on rock
Rock fall
Fall on snow
Fall/Slip on trail
Sunburn
Immersion/submersion
Overuse injury
Preexisting medical condition
Missing/Lost
Hygiene
Pre-existing Psychological or Mental Health Issue
Screening
Supervision
Misbehavior
Instruction
Interpersonal conflict
Not following instructions
Group Dynamics
Lack of belonging/inclusion
Bullying
Discrimination/Harassment
Motivational Issue
Behavioral Issue
Unknown
Other - Please Explain
Were there additional Contributing Factors?
*
Please Select
Yes
No
Please list any other Contributing Factors
Altitude
Weather
Avalanche
Cold Exposure
Animal Encounter
Visibility
Loose Rock
Falling tree/branch
Plant poisoning/toxicity/contact
Technique
Equipment
Technical systems failure
Inattention
Carelessness
Exhaustion
Dehydration
Fitness/ability
Exceeded Ability
Fall on rock
Rock fall
Fall on snow
Fall/Slip on trail
Sunburn
Immersion/submersion
Overuse injury
Missing/Lost
Preexisting medical condition
Pre-existing psychological or mental health issue
Hygiene
Screening
Supervision
Instruction
Not following instructions
Misbehavior
Interpersonal conflict
Group Dynamics
Bullying
Lack of belonging/Inclusion
Discrimination
Behavioral
Motivational
Unknown
Other
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.
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Prepared By:
First Name
Last Name
Preparer's Position:
Preparer E-mail
Preparer's Signature
Preparer Signature Date
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Reviewed by:
First Name
Last Name
Reviewer Position:
Reviewer Signature
Reviewer Signature Date
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