Incident Report Form Student Name* First Last Student email/contact infoWhen possible, enter student email or cell #Program* Environmental Technician Forestry Technician Outdoor Adventure Outdoor Adventure Naturalist Urban Forestry Course Leader Name* First Last Instructor Name* First Last Date of Incident* MM slash DD slash YYYY Program Activity*Course Day #*# Staff*# Participants*Weather at Time of Incident*Type of Incident* Injury Illness Motivation/Behaviour Near Miss Is this a lost-day case?* Yes No Did the victim leave the field?* Yes No Evacuation Method* Unassisted (walk, bike, ski, etc...) Litter Vehicle Air-Evac No Evac Where was the drop-off location? Hospital Home College Did the victim return to the course?* Yes No Type of injury Bruise, contusion or similar soft-tissue trauma Ligament sprain Muscle strain Frostbite Fracture Dislocation Head injury WITHOUT loss of consciousness Head injury WITH loss of consciousness Near drowning or other submersion Immersion foot Tendonitis Eye injury Dental or tooth-related Burn Blisters(s) Laceration Skin abrasion Sunburn Other Please provide details*Anatomical Location of Injury (indicate left/right)*Type of Illness Allergic reation MILD, localized Allergic reation Severe, generalized Allergic reaction ANAPHYLAXIS Hypothermia or heat illness (specify temp) Upper respiratory illness Upper respiratory illness (runny nose, congestion, "cold") Upper respiratory illness (other) Chest pain or cardiac condition Abdominal or other gastrointestinal problem including diarrhea Apparent food-related illness Non-specific fever illness Urinary tract infection Skin infection Eye infection Other Please provide details*Immediate Cause (prioritize if needed 1,2,3)* Fall on snow Fall on rock Fall/slip on trail Dehydration Cold exposure Technique Pre-existing medical condition Overuse injury Failed to follow instructions Carelessness Exceeded ability Exhaustion Psychological Misbehaviour Supervision Instruction Equipment Weather Other Please provide details*Narrative (what and how)*In-field management (treatment, diagnosis, etc.)*Follow-up (outcome, transport, location)*Report prepared by:*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Δ