Incident Report Form
To be completed by the activity leader/s as soon as practical after the incident. This report should be kept by the club secretary as a formal club record. Complete a report even if an insurance claim is not likely to occur, or an incident is a ‘near miss’.
Please email the completed form to safety@bushwalkingvictoria.org.au for our Safety Committee to evaluate the incident and extract any learnings that will be useful to the wider bushwalking community.
| CONTACT DETAILS | ||
| Club Name: | ||
| Report prepared by:
(name and club role): |
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| Date prepared:
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| Date & time of Incident: | ||
| Activity leader details:
(full name, phone, email) |
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| Full Name of affected person: | ||
| Address of affected person:
(home address, email)
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| Witness details:
(full name, phone, email) |
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| Did the person sign the Club’s Acknowledgement of Risk Form
(as part of annual membership renewal or prior to the activity in the case of temporary members): |
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| Does the affected person have Ambulance Cover? | ||
| ACTIVITY DETAILS | ||
| Type of Event: (Day walk, base camp, multi-day walk, special event, etc.) | ||
| Activity Location
(Name of park, forest or area of the walk): |
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| Track Name: | ||
| Track Conditions at the time of the activity: | ||
| Weather Conditions at the time of the activity: | ||
| Relevant potential hazards identified prior to the activity: (i.e. river levels, crossings, slippery rocks, roads, elevation, etc.)
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| INCIDENT DETAILS
(attach separate report if required) |
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| Location on the track where the incident occurred: |
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| Describe the incident and any resulting injuries, if applicable: |
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| Actions Taken: | ||
| Details of emergency response teams:
(Who, how long did they take to reach the affected person/s, how were they contacted) |
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| Post incident follow-up with affected person/s: | ||
| Any suggestions on how the likelihood of such an incident might be reduced? | ||
| SUPPLEMENTARY INFORMATION | ||
| Please include any maps, photos, witness statements, etc.
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Privacy Note
The inclusion of the names of individuals and their contact details in this report must be done in accordance with relevant Privacy laws.
| Signed: | Signed: | |||
| Activity Leader | Witness
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| Name: | Name: |