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Three Rivers Incident Report Form
SCOPE: To ensure a safe community boating facility, all occurrences of injury (major or minor),
collision, flipping, etc must be reported using this form. See details below. Thank you.
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Your Email Address:
*
Your answer
Your Name:
*
Your answer
Your Phone Number:
*
Your answer
Your Program/Affiliation:
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Your answer
PROCEDURE
1. This Incident Report Form (IRF) is to report:
a. Any person overboard
b. Swamping or flipping, including singles
c. Any personal injury, no matter how small or insignificant.
d. A collision
e. Any other instance of unsafe conduct.
2. The person responsible for filing this IRF is:
a. The coach or Crew Leader in charge at the time of the incident.
b. The person involved in the incident if no Coach or Crew Leader was required.
c. Any person who observes a breach of the TRRA Rules and Regulations.
3. IRF’s must be filed using this form within 24 hours of the incident. This competed form will go to the TRRA Safety Committee and the TRRA Executive Director.
a. Failure to submit within 24 hours may result in immediate suspension of membership or privileges at TRRA.
DIRECTIONS
1. Complete this IRF in its entirety with as much detailed information as possible within 24 hours of the occurrence
of the incident.
2. Follow up with the TRRA Executive Director and Safety Committee as necessary.
Date of Incident:
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MM
/
DD
/
YYYY
Time of Incident:
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Time
:
AM
PM
Were there any injuries?
*
Yes
No
Was any equipment damaged? If TRRA equipment was damaged please fill out separate damage report form.
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Yes
No
Check the appropriate box. If incident is not listed, write-in.
*
Collision
Swamping or Flipping
Injury
Violation of TRRA Rules and Procedures
Witness to Unsafe or Illegal Conduct
Other:
Required
Describe the Incident in Detail:
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Your answer
Number of Persons Involved:
*
Your answer
Number of Persons Requiring Treatment:
*
Your answer
Flow at the time of incident: (
https://water.weather.gov/ahps2/hydrograph_to_xml.php?gage=shrp1&output=tabular
)
*
Your answer
Water temperature at the time of incident: (
https://waterdata.usgs.gov/nwis/uv?cb_00010=on&format=gif_default&period=7&site_no=03049640
)
*
Your answer
Air temperature at the time of incident: (
https://w1.weather.gov/data/obhistory/KAGC.html
)
*
Your answer
Wind speed and direction at the time of incident: (
https://w1.weather.gov/data/obhistory/KAGC.html
)
*
Your answer
General description of conditions:
*
Your answer
Any other additional information:
Your answer
Please send photos and images, if necessary, to
safety@threeriversrowing.org
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