Patient Details

Enter name

Select gender

Enter date of birth

Enter SLSNZ number

Enter telephone

Enter address

Enter email

Incident Details

Select activity type
Select equipment used

Provide description of property/ material damaged

Select type of injury

Provide description of body injury

Provide any other information

Risks on Day

Describe primary cause of incident and conditions on the day

Please select level of risk associated with items below

Swell size

Wave type

Tide/ current

Time between sets

Depth of water

Geography/ topography

Beach debris

Water quality

Wind

Temperature

Coastal defences

Other man-made structures

Hazardous substances

Beach/ water population

Activities/ events

Behavioural

Vulnerable groups

Other water users

Available light

Treatment and Action

Describe initial treatment

Describe recommended action

Attach incident action plan
Attach completed risk assessment

List any other agencies involved

Are there likely to be claims relating to this incident (ACC, insurance etc.)

Was there any training prior to the incident?

Was the equipment checked prior to use?

Were emergency communications available?

Was first aid equipment available?

Was safety cover available?

Witness Details

Add witness

Name

Contact phone details

Age

Injury (if injured)

Role

Signature

Signed by incident investigator