Youth Programs Incident, Illness, Injury and Near Miss Report Form

Colorado Mountain Club's Incident, Illness, Injury and Near Miss Report Form, collected by CMC Staff to compile data.

CMC 24 Hour Emergency Call Service (269) 384-1056 if you need to connect with staff 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

Your E-Mail Address

First & Last Name of person completing this report

Date and Time of incident:

Program Name

Number of people in party

Geographic Location / Route

First & Last Name of primary injured person/s or person/s primarily involved in incident

What was their role on the trip?

Type of report

Narrative Description (SOAP Format)

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

If you are filling out this form for a near miss or minor injury (band aid) you can submit the form now. If you are filling out the form for a incident, injury, or illness please complete the following questions below. See questions below for incident (behavioral), injury, or illness follow up questions.

Estimate of their experience for this activity

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

Type of activity what activity was the participant participating in at the time of the injury? Please be specific. example: rock climbing, hiking, slacklining, park ranger, etc.

Estimated Elevation What is the estimated elevation that the incident occurred at.

Preferred Phone phone number that we can use to contact you in the future if there are any questions regarding this incident report.

Type of Injury or Illness (choose multiple if applicable) If you do not know the type of injury or illness, or see it listed below, please click other and write a description in the additional narrative box at the bottom.

Location/conditions present during incident / injury / illness (check all that apply) If you do not see the condition listed, click other, and add it to the additional narrative below.

Immediate Cause What immediately happened to cause this incident? Examples: slip on snow, act of nature- rockfall, participant exceeded abilities, participant got separated from the group, equipment failure, exhaustion, darkness, climbing unroped, etc.

Follow Up Write here, how you plan to follow up on this incident. Did you contact the admin support for the day? What is your plan for communicating with guardians, teachers, chaperones, etc.

Any additional notes/narrative, please add here

Youth Programs Incident, Illness, Injury and Near Miss Report Form

CMC

The CMC

Connect with the CMC Community

Connect with the CMC Community