INCIDENT REPORT Name of Person completing report(Required) First Last Date of incident(Required) Time of incident(Required) Hours : Minutes AM PM AM/PM Location of incident(Required)Provide details on weather, physical environment, and surroundings Name of Person report pertains to(Required) First Last Phone (if known)Email (if known) Type of Incident(Required) major First Aid Minor First Aid Major Rescue Drowning Jellyfish Sting Bike Injury Interaction with wild animal Employee Injury Complaint Other - provide details below Nature of injury Marine Sting Abrasion / graze Blisters Open wound /laceration / cut Bruise / contusion Inflammation / swelling Fracture (including suspected) Dislocation/subluxation Sprain / Strain Overuse injury Concussion Cardiac problem Respiratory problem / Asthma Loss of consciousness Heat stroke / Heat exhaustion Hypothermia Sunburn Suspected spinal Other (provide details below) Body parts affected(Required)Type of activity at time of incident(Required)Administered treatment(Required)What did you do? What did anyone else do, who were they? Did you perform first aid? What medications were given if anyWitnesses to incidentNamePhoneEmail Add RemoveAfter Care Referral No referral Ambulance transport Dr Peer Counselling