PCHC Incident-Injury-Event Form

PebbleCreek Hiking Club

Incident/Injury/Event Report

Purpose: The intent of the Incident/Injury/Event Report is to capture information from injuries, incidents and other events so that actions to prevent a reoccurrence can be identified when possible and changes in club policy be implemented when needed.

What to report: Any significant injury, health incident, or hiker voluntarily turning around. This includes events requiring more than self-treatment by the hiker, use of Club Medical Kit items, need to walk the hiker off the trail, InReach activation, or 911 call.

Responsibilities: The Hike Leader will determine whether an incident should be reported. A minor abrasion, for example may not need to be reported. The Hike Leader is responsible for completing this Report Form directly after the hike and submitting it to the Safety Committee and/or Hiking Club President for review. The Hike Leader will determine, in conjunction with the President and/or Safety Committee, who will replace any medical supplies used from the Medical Kit.

Date of Hike:

YYYY

Time of Incident

Hiker Name

Please select the Hike Level

Hike Name and Region:

Describe the Injury/Incident/Event:

First Aid Provided / Level of Medical Coverage / Other Actions Taken:

Medical Supplies Used from the Hiking Club Medical Kit:

Plan for Medical Kit Item Replacement:

Hike Leader or Submitter Name:

Hike Leader or Submitter Email Address:

Hike Leader Signature

Witnesses