Incident Report Form

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Incident Report

Club: Illawarra Ramblers Inc.

"*" indicates required fields

Reported by*

This can be the person affected, the leader or a participant who witnessed the incident

First name Last name

Phone no.*

Activity*

e.g. Mount Keira ring track

Grade of activity

(if known)

Please enter a number from 1 to 5.

Type of activity*

Walk

Cycle

Paddle

Leader's name*

First name Last name

Name of injured person*

First name Last name

Address of injured person

(if known)

Phone no. of injured person

Date of incident*

Time of incident

Weather conditions

Location of incident*

Type of incident or injury*

Incident details*

External involvement

e.g. authorities or other agencies notified

Witness 1

First name Last name

Phone

Witness 2

First name Last name

Phone

Additional information

e.g. attachments, photos

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 16 MB, Max. files: 3.