Title Page
-
Document No.
-
Club
-
Incident Date and Time
-
Incident Location
-
Incident Investigated By
Patient Details
-
Enter name
-
Select gender
-
Enter date of birth
-
Enter SLSNZ number
-
Enter telephone
-
Enter address
-
Enter email
Incident Details
-
Select activity type
- Training
- Patrol
- Callout
- Event
- Other
-
Select equipment used
- Vehicle
- Surf Boat
- Board
- IRB
- Ski
- Other
-
Provide description of property/ material damaged
-
Select type of injury
- Abrasion
- Burn
- Bruising
- Fracture
- Pain
- Poisoning
- Haemorrhages
- Laceration
- Allergic reaction
- Disloaction
- Suspected spinal injury
- Crush
- Other
-
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
