Incident Report
Fill out this form. 
Sign in to Google to save your progress. Learn more

Date

MM
/
DD
/
YYYY
River Section

Customer name and name of booking party (if applicable)

Exact Location(s)
Who is filling out this form (please provide contact information)
Name all other staff members and guides who were there with you. Was there a designated Trip Leader? If so, who?
Name all other witnesses to the incident, and of these witnesses, which ones do you recommend we reach out to for a statement if necessary? 

Objective description of incident:

Simple injury description or code (if applicable)

Example: Patient sprained wrist

Answer this question if First Aid was administered by your crew.

If a patient assessment was done, send a picture of notebook or whatever was used to record this assessment to triadraft@gmail.com and note the time that this email was sent in your answer.

Was this person transmitted to a medical provider? If so, what provider and what was the name of the person who you transferred care of the patient to?

First Aid (if applicable) details:

Example: Was the patient stabilized and or moved? If so, explain how this was done.

Example: Did this patient say anything about how they were injured to indicate a MOI or NOI?

If First Aid was administered, was there a designated MO (Medical Officer). If so, who? (Note: This person must be included in submitting this report, or submit a separate report).

Evacuation (if applicable)

Was physical assistance provided to anyone during evacuation?

Describe the evacuation route, timing, and procedure utilized.

Provide a Timeline for the Incident
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms