APPENDIX E

PROJECT ADVENTURE

MAHOPAC MIDDLE SCHOOL

INCIDENT REPORT

Check one: Rescue ___ First aid ___ Other (specify) __________________

Name of injured __________________________________

Address _______________________________________________________________

Age ____ Sex _______ Date of incident _______________________ Time __________

Name and telephone of family contact ________________________________________

Site of occurrence: Low ropes (outside) ___ High ropes (inside) ___

                  High ropes (inside) ___ Other _____________

If incident occurred in a class, check one.

         General program ___ Professional Workshop ___ Elective Program__________

         Intramural activity ___ Other; please indicate: ___________________

Witnesses: Names, addresses, and telephone numbers

1. _________________________________________________________________

2. _________________________________________________________________

3. _________________________________________________________________

Cause of incident: _____________________________________________________

___________________________________________________________________

___________________________________________________________________

Type of injury: Area of injury:

Fracture___ Dislocation ___ Head ___ Trunk ___

Cut/Laceration ___ Sprain/abrasion ___ Neck ___ Leg ___

Other (specify) ________________ Arm ___ Foot ___

                                                      Hand ___ Multiple ___

                                                      Unknown ___

Incident Data

Date and day of week ___________________ Time of day ____________

Name of activity _______________________ Location of facility _________________

Number of Instructors on duty/Names ________________________________________

Weather conditions: Air temperature ____ Clear ___ Cloudy ___ Fair ___ Poor ___

Wind conditions: Wind direction ___ Light winds ___Moderate ___ Strong _____