EmailMe Form - Sailing Collective Incident Report

Please use this form for any incident involving injury or a near-miss*.
*A near-miss is any dangerous situation where injury was avoided.
Your Name
You may exclude your name and email for an anonymous report.
Where was your journey? *
Who was your captain? *
Who was your chef? *
Your Email
A copy of this form will be sent to you for your records
Incident info
Name(s) of those injured or involved
Date of incident
MM / DD / YYYY
Time of incident
Activity Participating In
Area where incident/near miss occurred:
Please describe location and setting
Description of the incident
Pleas be as descriptive as possible
Area(s) of body injured:
Description of the injury
Did equipment contribute in any way to the accident?
Yes
No
If yes please please include it in the incident description.
Describe any first aid given
Include a list of any medications given
Injured party’s mental status at the time of the accident?
Confused
Calm
Panicked
Aggressive
Other
The person's immediate response.
Photos

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You can also upload voice recordings or screenshots or any other relevant information that helps to describe the incident.