Instructions for using the Incident Report form

Preface

The Victoria Club Tread Incident Report form was assembled from various forms used by other organizations. The purpose is to document incidents on our events for emergency responders. The forms have the additional function of providing an opportunity to learn of incidents and develop policies to help prevent similar incidents in the future.

This form should be used for all incidents, including those in which emergency services were not called. The form should be used for:

• Injuries
• Lost individuals
• Significant weather related incidents
• Other incidents that warrant discussion by the safety committee

Privacy

This form has been reviewed by a former acting director for the Office of the Information and Privacy Commissioner of British Columbia. Information on the forms will be shared with first responders. Anonymized versions of the form may be shared with the Victoria Club Tread Safety Committee.

Emergency Responders

If emergency responders request the form it must be given to them. Attempt to recreate the form as best you can afterwards. In this case note that the original form was taken by the first responders and that the new form is a best recollection of the contents of that form.

Storage

Forms should be returned to the Outdoor Event Coordinator. These forms should be saved for at least 7 years.

Fields

Field	Use
Coordinator name	The name of the event coordinator. If there are multiple coordinators list all of them.
Address	The address of the event coordinator.
Phone #	The event coordinator's phone number.
Date	The date the of the incident.
Time of incident	The time of the incident.
Weather conditions	Note the weather conditions at the time of the incident.
Terrain	Note the terrain on which the incident occurred.
Time of emergency services contact	If emergency services were contacted, note the time the call was made. If one or more people were sent to make the call, note the time they were sent and the time they placed the call.
Time of emergency services arrival	Note the time that the first emergency services person arrived.
Brief account of incident	Provide a brief account of the incident. Give factual information only, do not assign blame.
Witnesses' names and phone numbers	Note the names and phone numbers of all people who witnessed the incident.
Subject information	All fields are provided at the discretion of the individual involved in the incident. If the individual is unconscious then implicit consent is assumed.
Subject name	The name of the person involved in the incident.
Age	The person's age.
Gender	The subject's gender.
Address	The subject's address.
Home phone	The subject's phone number.
Contact person/phone number	The name and phone number of the individual's contact person. In the event the subject is unconscious then take the information from the waiver.
Initial assessment	The fields under this heading represent the initial assessment only. For ongoing care/changes in condition use the "Care" section on the next page.
Airway	Check that the subject has a clear airway. Administer aid if necessary.
Breathing	Assess the subject's breathing. Count the number of respirations per minute.
Circulation	Check and record the subject's pulse. Note the colour and feel of the skin, is it warm or cold? Is it dry or clammy?
AVPU	The AVPU scale (Alert, Voice, Pain, Unresponsive) is a system by which a first aider, ambulance crew or health care professional can measure and record a patient's responsiveness, indicating their level of consciousness. Always work always work from best (A) to worst (U) and stop once a level is determined. Alert - a fully awake (although not necessarily orientated) patient. This patient will have spontaneously open eyes, will respond to voice (although may be confused) and will have bodily motor function. Voice - the patient makes some kind of response when you talk to them, which could be in any of the three component measures of Eyes, Voice or Motor - e.g. patient's eyes open on being asked "are you okay?!". The response could be as little as a grunt, moan, or slight move of a limb when prompted by the voice of the rescuer. Pain - the patient makes a response on any of the three component measures when pain stimulus is used on them. Recognized methods for causing the pain stimulus include a Sternal rub (although in some areas, it is no longer deemed acceptable), where the rescuers knuckles are firmly rubbed on the breastbone of the patient, pinching the patient's ear and pressing a pen (or similar instrument) in to the bed of the patient's fingernail. A fully conscious patient would normally locate the pain and push it away, however a patient who is not alert and who has not responded to voice (hence having the test performed on them) is likely to exhibit only withdrawal from pain, or even involuntary flexion or extension of the limbs from the pain stimulus. The person assessing should always exercise care when performing pain stimulus as a method of assessing levels of consciousness, as in some jurisdictions, it can be considered assault. This is a key reason why voice checks should always be performed first, and the person assessing should be suitably trained. Unresponsive - Sometimes seen noted as 'Unconscious', this outcome is recorded if the patient does not give any Eye, Voice or Motor response to voice or pain. If the result is anything other than "A" contact emergency services.
Page 2
Subject's sample	The signs, allergies, medications, medical history, eating and events.
Signs and symptoms	Note the subject's signs or symptoms.
Allergies	Note any allergies the subject has.
Medications	Note any prescription/non-prescription medications the subject is taking.
Past medical history	Note any past medical history for the subject.
Last meal or snack	Note the time of the last meal or snack consumed by the individual.
Events leading up to Incident	List the events leading up to the incident.
Care	List the time and care given to the subject.