Ski Area Accident Report

Report

Accident number

Season (year 1 / year 2)

/

Report number

Resort / ski area

Incident date

Incident time (24 hr)

Patient

Name

Visitor local accommodation info

Home address

City

Prov

Postal code

Phone

Occupation / school group

If a student, in a school ski program?

Date of birth

AgeFilled from date of birth

Gender

Height

Weight

Patient type

Ticket type

Patient's description of incident

Signs and symptoms as recorded by patroller/doctor

Signed

XSign here with finger or mouse

Initial here if treatment is refused

Recurrence of previous injury?

Time of last meal

Allergies

Medications

Related medical history

Drugs / alcohol

Complaint

Injured areas

Tap L for left, R for right, B for both. Tap again to clear.

Other areas

Other injury

If multiple, primary injury

Treatment protocol

Other treatment

1st Aid

On scene

Transported

Base/clinic in

Base/clinic out

At scene

Base / clinic

Medication administered

Time

By

Attachments

Witness

Location

Run

Map / grid coordinates

GPS

Exact location

Incident location

Park feature / size

Run classification

Activity

Involvement

Days this year, at this area

Days this year, at all areas

Days

Times on this run/lift before

When?

Conditions

Weather

Light

Temp (°C)

Snow (cm)

Surface

Equipment

Binding release

Ability

Helmet

Lesson

yrs ago

Rental boot #

Rental ski #

Collided with a person or object?

If yes, describe

If not a collision, primary cause

Non-collision

Lift related

Non-skiing related

Transport

To first aid

From base

Destination

Patrollers

Sign-off

Form completed by (print)

Patroller #

Date

Signed

XSign here with finger or mouse