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DETAILS OF ACCIDENT
Region: / Zone:
Scout Group: / Section:
Type of Activity: / Activity Location: (Grid Reference)
Activity Leader / Skills/Experience:
Weather at the time of Accident: / Fine...... Wet
Hot...... Cold
Calm...... Windy
High Vis...... Low Vis. / Communication method used to raise help: / Mountain Radio
VHF Radio
Satellite Phone
None used / Avalanche Tr.
Locator Beacon
Messenger
Other
Number of people on activity: / Leaders / Participants / Others / Type of Accident: / Fatality
Injury
Illness
Psychological / Equipment loss
Equipment damage
Missing/Lost
Other
Date of Accident:
Time of Accident:
SEVERITY RATING (select one grade of severity).
Major Accident
(report submitted to both National Office and Group) / Minor Accident
(report submitted to Group only)
10. Extreme..... (multiple fatalities)
9. Grave...... (single death)
8. Severe...... (major injury/long term hospitalisation)
7. Major...... (major injury/hospitalisation > 12 hours)
6. High...... (major injury/hospitalisation < 12 hours) / 5. Medium...... (medium injury/sprain or minor fracture)
4. Modest...... (Lacerations/mild concussion)
3. Low...... (Blisters/minor dislocation)
2. Minor...... (Severe sunburn/minor cuts)
1. Minute...... (Splinters/insect bite)
DETAILS OF PERSON INVOLVED (use extra sheets if more than one person).
First Name: / Last Name:
Age: / Ethnicity:
Gender: / Evacuation method:
TYPE OF INJURY SUSTAINED (you may select more than one).
Abdominal problem
Abrasion
Allergy
Altitude sickness
Asthma
Blister
Bruise
Burn / Chest pain
Concussion
Contusion
Eye Injury
Eye Infection
Dislocation
Fatigue
Food poisoning / Fracture
Frostbite
Heat stroke
Hyperthermia
Hypothermia
Infection
Laceration
Muscle strain/tear / Near-drowning/drowning
Puncture
Psychological problem
Respiratory problem
Sprain
Strain
Other (state)
CAUSAL FACTORS INVOLVED(you may select more than one).
People / Equipment / Environment
Activity Leader / Participant
Inadequate physical condition
Inadequate mental condition
Inadequate emotional condition
Pre-existing condition
Judgment/Leadership error
Inadequate supervision
Inadequate skills/experience
Failure to follow guidelines
Lack of motivation
Other / Inadequate physical condition
Inadequate mental condition
Inadequate emotional condition
Pre-existing condition
Judgment/Leadership error
Inadequate supervision
Inadequate skills/experience
Failure to follow instructions
Lack of motivation
Other / No equipment
Wrong equipment
Faulty equipment
Inadequate equipment
Other
N/A / Adverse weather
Poor visibility
Terrain
Water (rain/rivers etc)
Animal/Insect/Plant
Other
N/A
Explanation:
TYPE OF ACTIVITY(you may select more than one).
Abseiling
Archery
Bungy jumping
Bush craft
Camping
Canoeing
Caving
Commando course
Cooking
Cycling
Field trip / Fishing
Flying fox
Horse riding
Hunting
Initiative activities
Kayaking
Land yachting
Mountain biking
Mountaineering
Multisport/Adventure Racing
Orienteering/Rogaining / Pioneering
Rafting
River crossing
Rock climbing
Ropes course
Sailing
Scuba diving/Snorkelling
Sea kayaking
Skiing
Snow boarding
Snow caving / Solo trip
Surfing
Swimming
Tramping
Transportation
Tubing
Weekly activity
Windsurfing
Waterskiing
Other
Narrative:

May 2010 accident_report_form.doc