Incident Response Form

To be completed by activity leader as soon as possible after the incident. This form is part of our risk management policies and procedures.

An incident is an event which may result in a claim being made, such as serious injury, death, damage to third party property or loss of possessions. An accident is where a person is injured. A serious injury is one requiring medical attention.

Report prepared by

Date prepared

Date of incident

Time of incident

Name of injured person or person suffering loss

Phone number

Address of injured person or person suffering loss

Name of activity

Grade

Location where the incident occurred

Type and description of the incident (injury, missing person, damage to property, fire, theft etc)

Describe actions taken

Were authorities or other agencies notified at the time?

Yes No

If yes, who contacted external authorities, how, and did the external authority take a role in managing the incident?

Have the insurers been notififed?

Yes No

What was the final outcome of the incident, was it resolved?

Could the likelihood of this incident be reduced at future Club activities? If so, how?

Name and address of witnesses to the incident

Upload documents eg witness statements, maps, photos

Coffs Hikers

Incident Response Form

Clouds Creek Falls

Canceled Peninsula Tracks, Bongil Bongil

Mt Gladstone