Incident and Near-Miss Reporting Form

Incident and Near-Miss Reporting Form

Please use this form to report incidents and near misses (occurrences) that happen on all section-sponsored activities/trips, as well as activites organized by the National Office. A copy of this report will be sent to your section chair, the safety committee and the ACC’s Executive Director at National Office.

Please provide as much detail as possible about the occurrence, the conditions at the time and the actions taken by the group or outside rescuers. Pictures of the occurrence site and the exact location of the occurrence site are immensely useful for the reviewers.

This form will use "Occurrence" in place of Incident /Near Miss
Event Name
Section that Organized Trip*
Section Chair's Email
Will be sent a copy of this report
Date of Report*

MonthDayYear
Time of Day of Occurrence

:HourMinutesAM/PM Option
Date of Occurrence*

MonthDayYear
Report completed by:*

First NameLast Name
Reporter's Email*
Reporter's Phone Number*

Area CodePhone Number
Reporter's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reporter is the same as Trip Coordinator

YesNo
Trip Coordinator /Leader/ Organizer

First NameLast Name
Rope Leader (If applicable)

First NameLast Name
Others Involved:
Please include all group members
Type of Activity

Rock ClimbingIce ClimbingMountaineeringHiking/TrekkingBackcountry Skiing (or Split boarding)Social EventOther
Report is for:

Near MissIncident
Location of incident (description and map reference or GPS coordinates where available)*
Occurrence Description*
Other Witnesses
Number Of People Involved In Group
Number Of People Involved In Occurrence
Conditions (weather, snowpack, ice, loose rock, visibility, temperature, etc)
Equipment Involved
If possible please preserve and photograph damaged equipment for analysis
Primary Cause (you may select more than one primary cause)*
Primary Cause (Text description)
Contributory Causes (you may select more than one contributory cause)
Contributory Cause (Text description)
Other Significant Contributing Factors
Person Injured / At Risk

First NameLast Name
Person Injured / At Risk Phone #

Area CodePhone Number
Address of Injured / At risk

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Additional People Injured / At Risk (include contact information!)
Type of Injury (if applicable, you may select more than one)
Type of Injury (text description)
Any other comments/ description of injury
Treatment Administered
Rescue Description
Why did the incident occur
Ex. Biases, Weather, overconfidence, poor communication, ect
What was learnt?
How could this have been done differently to avoid a similar incident in the future?
Any Additional Comments
Please upload any supporting documents (photos, field notes, etc)

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