CMC Incident, Illness, Injury and Near Miss Report Form

CMC 24 Hour Emergency Call Service (269) 384-1056 if you need to connect with staff for emergencies in the field. Please complete this form as soon as reasonable following the incident. This form is how you file your incident report. If you have taken notes on the paper copy or pdf, please enter them here so we have a digital file. This form is collected by CMC staff to compile data on our incidents and near misses in the field. Personal details and contact information is only used to follow-up as needed to fill in incomplete information or check on the well being of someone who left the field without a follow-up by the trip leader/instructor. The compiled data will be used to report on our incidents and near misses club-wide to inform better risk management, places we may need to increase training, and compare data to similar organizations. Thank you for your leadership and communication of this incident or near miss in the field.

  = required field

Submitter Name   Enter your first and last name or the first and last name of the interviewee if you are submitting this report on another's behalf.

Submitter Email   Enter your email address or the email address of the interviewee if you are submitting this report on another's behalf.

Report Category  

Incident (physical)Incident (behavioral)Near Miss / Near Hit / "Close Call"

First & Last Name of primary injured person/s or person/s primarily involved in incident along with contact information   Include multiple if appropriate) E.g. Jane Doe / jdoe@gmail.com / (###) ###-####

What was their role on the trip?

Student / Participant (CMC Member) Guest (non CMC Member) Leader Instructor

Estimate of their experience for this activity

Experienced (3+ years) None or little (<1 year) Moderate (1-3 years)

First & Last Name of WITNESSES to the incident along with contact information Include multiple if appropriate. E.g. Jane Doe / jdoe@gmail.com / (###) ###-####

Date and Time of Incident  

# of people in party

Geographic Location / Route Please include a description of your location (e.g. North Side of Chasm Lake 11378'). Please also include Lat / Long information if its available (e.g. 40.26342, -105.59434)

Trip Name and Number E.g. TCS Rock Seconding / #55192

Group

StateDenverBoulderPikes Peak GroupNorthern ColoradoWestern SlopeEl PuebloRoaring Fork

Mileage, Elevation +/- Enter the mileage and elevational gain and loss up to that point (for the day).

First & Last Name of Person(s) completing this report E.g. John Doe

Preferred Phone for contact

Type of Injury or Illness (choose multiple if applicable)

Fatality Frostbite Head Injury HAPE Hypothermia Head Injury - Conscious Head Injury - Loss of concsciousness HACE AMS Sprain Strain Fracture Abrasion Laceration Infection Mental Health Pre-existing condition

Location / Conditions present during incident / injury / illness (check all that apply)  

Rock Snow Ice On Trail Off Trail Scrambling Creek / River

Mode of Travel

AscendingDescendingFlat Terrain

Immediate Cause   Check all that apply

Fall or slip on rock Fall or slip on snow Fall or slip on ice Fall or slip on loose dirt / gravel Fall or slip on other Act of nature - rockfall Act of nature - avalanche Act of nature - lightning Subject/s exceeded abilities Subject/s became stranded Subject/s became separated from group Subject/s failed to follow route Subject/s wasn't properly equipped Subject/s failed to test hold Subject/s lost control on descent Other

Further Description of Immediate Cause

Contributory Cause Check all that apply

Climbing unroped Darkness Party Separated Exhaustion Exceeding Abilities Weather Equipment Failure Other

Narrative Description   What happened and if a "near miss" report, what might have happened)

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Analysis What knowledge and techniques, if any, will help prevent future incidents / illness / injury?

text/htmltext/x-web-textile

Follow up   Did you or another leader contact the patient after the incident?

YesNo

Attachment 1 (optional) A photograph, Word, PDF, zip file, etc. may optionally be attached to provide additional details for the Safety Committee.

Attachment 2 (optional) A photograph, Word, PDF, zip file, etc. may optionally be attached to provide additional details for the Safety Committee.

Thank you for submitting this report. If you would like to contact Graham Ottley to share additional information please contact at graham@cmc.org.