Title Page
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Document No.
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Club
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Incident Date and Time
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Incident Location
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Incident Investigated By
Patient Details
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Enter name
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Select gender
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Enter date of birth
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Enter telephone
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Enter address
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Enter email
Incident Details
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Select activity type
- Training
- Patrol
- Callout
- Event
- Other
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Select equipment used
- Vehicle
- Surf Boat
- Board
- IRB
- Ski
- Other
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Provide description of property/ material damaged
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Select type of injury
- Abrasion
- Burn
- Bruising
- Fracture
- Pain
- Poisoning
- Haemorrhages
- Laceration
- Allergic reaction
- Disloaction
- Suspected spinal injury
- Crush
- Other
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Provide description of body injury
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Provide any other information
Risks on Day
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Describe primary cause of incident and conditions on the day
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Please select level of risk associated with items below
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Swell size
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Wave type
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Tide/ current
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Time between sets
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Depth of water
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Geography/ topography
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Beach debris
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Water quality
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Wind
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Temperature
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Coastal defences
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Other man-made structures
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Hazardous substances
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Beach/ water population
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Activities/ events
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Behavioural
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Vulnerable groups
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Other water users
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Available light
Treatment and Action
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Describe initial treatment
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Describe recommended action
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List any other agencies involved
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Are there likely to be claims relating to this incident (legal, insurance etc.)
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Had the surf lifesaver undergone training prior to the incident?
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Was the equipment checked prior to use?
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Were emergency communications available?
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Was first aid equipment available?
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Was safety cover available?
Witness Details
- Add witness
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Name
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Contact phone details
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Age
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Injury (if injured)
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Role
Signature
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Signed by incident investigator
