Canyoning Incident Report

• Date/time

  Date

• Prepared by

  Select Marcio Dom Spence Pete Paige Barry Other

  • Marcio
  • Dom
  • Spence
  • Pete
  • Paige
  • Barry
  • Other

• Role on the day (tour leader, photographer, trainee etc)

• Full name

• DOB

• Gender

  Male

  Female

  Other

• Phone number

• Home address

• Australian address (if different)

• Have you filled out a waiver form?

  Yes

  No

  N/A

• Booking reference number

• Tour activity

• Water level

• Conditions

• Time

• Status

  Employee

  Guest

• Insurance- number

• Allergies, previous medical conditions, comments

Details of Incident

• Date of incident

  Date

• Tour

  Crystals

  Behana

  Spillway

  Barron

  Tully

• Exact location of incident

• Nature of the injury (fracture, sprain graze etc)

• Cause of injury (fall, trip, hitting object etc)

• Location of injury

  Drawing

• Location of injury (text)

• Describe in detail how the incident occurred

Details of treatment

• Was treatment given?

  Yes

  No

  N/A

• If yes, by who?

  Select Marcio Dom Spence Pete Paige Barry Other

  • Marcio
  • Dom
  • Spence
  • Pete
  • Paige
  • Barry
  • Other

• Description of treatment

• Did we tell the injured person to go to the hospital/doctor?

  Yes

  No

  N/A

• Did the injured person request to go to the hospital/doctor?

  Yes

  No

  N/A

• Did the injured person visit the hospital/doctor?

  Yes

  No

  N/A

• If yes to any of the above, Details: location/doctor/time/follow up:

First aid provider

• Name

• Position/company

• Date

  Date

• Signature

  Sign

Witness to incident

• Witness Staff name

  Select Marcio Dom Spence Pete Paige Barry Other

  • Marcio
  • Dom
  • Spence
  • Pete
  • Paige
  • Barry
  • Other

• Phone number

• Witness name

• Phone number

• Witness name

• Phone number

• Witness account of incident (per witness)

Comments

• Injured person's comments

• Staff member witness comments

• Tour leader's comments

Signatures

• Injured person

  Sign

• Tour leader

  Sign

• Staff witness

  Sign

• Witness

  Sign

• Witness

  Sign