Schuss Mountain - Incident Report

• Incident Title

• Date and Time

  Date

• Prepared by

Patient Information

• Name

• Address:

• Home Phone: Other numbers:

• Sex

  male

  female

• Date of birth

• Height

• Weight

• Incident Location

  Yes

  No

  N/A

• Feature or jump #, count from to of park

• Feature Name

• Did you enter the park through entrance gate?

  Yes

  No

  N/A

• Did you read the info and warning signs posted at entrance?

  Yes

  No

  N/A

• How many times were you in this park today?

• This season?

• How many times have you ridden this feature today?

• Did you scope out the feature before using it today?

  Yes

  No

  N/A

• Do you believe the incident was due to action/ inaction on your part?

  Yes

  No

  N/A

• Arrived at Aid Station Via

  Yes

  No

  N/A

• Departed Via

  Yes

  No

  N/A

• Destination

  Yes

  No

  N/A

• Patient Description of Incident

• The above statement is true and correct

  Sign

• Pertinent Prior Injury?

  Yes

  No

  N/A

• If Yes, explain:

• Corrective Lenses?

  Yes

  No

  N/A

• Helmet worn at time of incident?

  Yes

  No

  N/A

Ski History

• In Lesson?

  Yes

  No

  N/A

• Ability

  Yes

  No

  N/A

• Equipment Type

  Yes

  No

  N/A

• Equipment Owner

  Yes

  No

  N/A

• Right Removed by

  Yes

  No

  N/A

• Binding setting Toe

• Binding setting Heel

• Left Removed by

  Yes

  No

  N/A

• Binding setting Toe

• Binding setting Heel

• Days at area this year

• Total days this year

• Falls today

Responsible Adult

• Relationship

• Name

• Address

• Phone

• Has Permission Slip

  Yes

  No

  N/A

• Parents contacted

  Yes

  No

  N/A

• Comments

Witness

• Name

• Address

• Phone

• Statement

• Name

• Address

• Phone

• Statement

Conditions

• Weather

• Temperature

• Snow

Patroler Working Incident

• Name

• Duty

  Yes

  No

  N/A

• Name

• Duty

  Yes

  No

  N/A

• Name

• Duty

  Yes

  No

  N/A

• Name

• Duty

  Yes

  No

  N/A

• Name

• Duty

  Yes

  No

  N/A

• Name

• Duty

  Yes

  No

  N/A

• Name

• Duty

  Yes

  No

  N/A

Probable Injury and Treatment

Vitals

• Time

• BP

• Pulse

• Resp

• Skin

• Pupils

• Temp

• AVPU

• Time

• BP

• Pulse

• Resp

• Skin

• Pupils

• Temp

• AVPU

• Time

• BP

• Pulse

• Resp

• Skin

• Pupils

• Temp

• AVPU

• Time

• BP

• Pulse

• Resp

• Skin

• Pupils

• Temp

• AVPU