Incident Date: * Incident Time: Subject Name: * Subject Status: * Staff Participant Other Gender: * Male Female Other Age: * Client Organisation: Program Type: * Course Location: * Course Director's Name: * Course Start Date: * Course End Date: * Number Of Staff On Course: * Number Of Participants On Course: * Incident Location: * Type of Incident: * Injury Illness Motivational/Behavioral Property Damage Near Miss Evacuation Missing Person Fatality Type of Injury or Property Damage: * Sprain or Strain Dislocation Fracture Tendonitis Laceration Puncture Blister Avulsion Sunburn Burn Frostbite Skin Eye Dental Bruise or Contusion Head Injury with no ALOC Head Injury with ALOC Near Drowning Other Property Damage If other, please specify: Type of Illness: * Abdominal or GI problem Diarrhea Mild allergic Reaction Severe Allergic Reaction (Anaphylaxis) Apparent food-related illness Skin Infection Eye Infection Upper Respiratory Illness Lower Respiratory Illness Chest Pain or Cardiac Condition Altitude Illness Hyperthermia Heat Illness Heat Cramps Heat Exhaustion Heat Stroke Non-specific Fever Illness Urinary Tract Infection Other If other or property damage, please specify: Wind Speed Precipitation: * Choose Rain Snow None Course Format: * Residential Basecamp Backpacking Canoeing Kayaking Challenge Course Other Anatomical Location of injury: * Head Shoulder Wrist Upper Back Thigh Foot or Toe Face Knee Upper Arm Neck Hand or finger Eye Chest Pelvis Lower Leg or Ankle Forearm Abdomen Hip Lower Back Elbow Other If other, please specify: Temperature: * Temperature scale: * Fahrenheit Celsius Visibility: * Choose Clear Limited If visibility is limited, limited to: (specify unit feet, miles, meters, km) Surface Conditions: * On trail Off trail Even Uneven Sloped Wet Dry Grass Sand Dirt Rock Mud Snow Ice Immediate Cause: Please number the major applicable causal categories from 1 to (n) with 1 being the most significant factor and (n) being the least. Altitude Avalanche Carelessness Cold exposure Visibility Dehydration Exceeded ability Exhaustion Fall/Slip Fall on rock Fall on snow Falling_rock Failure to follow instructions Falling tree/branch Hazardous animal Inadequate equipment Hostile bystander Immersion/Submersion Improper screening Intoxication Inadequate instructions Inadequate supervision Inexperience/poor judgement Missing/lost Overuse injury Lightning Misbehavior Poor technique Pre-existing condition Plant poisoning/toxicity Poor hygiene Tech/System failure Unfit Psychological Sunburn Unknown Weather Program Activity at Time of incident * Choose Backbacking Canoeing Cooking Day Hike In Camp Initiative or Game High Ropes Rappelling River Crossing Rock Climbing Sea Kayak Solo Swimming Unaccompanied Travel Unstructured Time Vehicle_Van Other If Other, please specify