Area*

Location*

Location of Incident*

Date*

Time*

: HH

MM

Duration*

: HH

MM

ALERTED TO INCIDENT BY*

Initial Incident Response undertaken By*

COORDINATED BY:*

Was Incident Escalated with request for Assistance from*

LOCATION OF THE INCIDENT:*

DISTANCE FROM SAFETY COVER:*

OPERATIONAL STATE OF THE BEACH:*

NATURE OF INCIDENT*

Male*

Number of male casualties

Female*

Number of female casualties

Equipment Used*

Other

Activity*

Other

NARRATIVE OF INCIDENT*

CAUSE OF INCIDENT

ENVIRONMENTAL*

Other

PHYSICAL*

Other

EQUIPMENT*

Other

BEHAVIOURAL*

Other

ENVIRONMENTAL CONDITIONS

WEATHER

WAVE HEIGHT

STATE OF TIDE

Inland

Canal
River
Lake
Other

Other

WIND CONDITIONS*

Operational State of Environment*

NAME*

I HAVE PROVIDED INFORMATION AS ACCURATELY AS POSSIBLE*

Response outcomes*

Was First Aid Administered?*

Was this Major or Minor First Aid?

Incident Report

Incident Report

Step 1 of 3

CAUSE OF INCIDENT

ENVIRONMENTAL CONDITIONS

Please refer to a doctor

Patient Report

PATIENT CONDITION (on initial examination)

Please refer to a doctor

Name	Paid/Voluntary (P/V)

Type of injury	Location of injury

Name	Paid/Voluntary (P/V)