Instructor Comments Please complete this form as thoroughly and accurately as possible if you had an injury to a student. LinkedInThis field is for validation purposes and should be left unchanged.Patrol IRF# (if available)This is a form that Ski Patrol fills out if the student was seen by patrol or admitted to the Emergency Medical ClinicDate of Incident* Time of Incident : Hours Minutes AM PM AM/PM Department*Meadows Learning CenterNordic CenterStudent Name* First Last Instructor Name* First Last Exact Location of Incident*e.g. Specific location of incident. Include trail map name, skiers right or left, proximity to intersections or fixed objects, etc.Which of the following best describes the incident?*On hill incident (other than collision)Collision with object or person (trees, built objects, etc.)Terrain Park incidentLift Related (maze, loading, riding or unloading)Premise Incident (parking lots, lodges, and decks/stairs, etc.)Motorized Vehicle Accident (involving a company vehicle)Physical altercationOtherDescribe the traffic at the location of the incident in terms relative to what is common traffic for that zone*Heavier than averageAverage for the areaLighter than the averageUnknown / I don't knowClass InformationLesson Type*AdaptiveAdult Camp or ClinicAdult Group LessonAdult Multi-week Program LessonFreeride TeamMid-week EducationalPrivateSnoBlastersTrail BlazersYouth Camp or ClinicYouth Daily Lesson (CLC)----MLC Voluntary TrainingMLC Paid TrainingLesson Discipline*AdaptiveAlpineCross CountrySnowboardTelemarkLesson Ability Level*First TimeNoviceGreenGreen/BlueBlueBlue/BlackBlackFreestyleIncident DescriptionWhere were you when the incident occurred?*Please describe how far away, uphill/downhill, to the side or in a different location altogether.At what point in the lesson did the incident occur?*Duration of time into the lesson (e.g. 30 minutes into the lesson), number of runs made (this was our 2nd run), etc.Did you witness the incident?*YesNoHow best would you categorize the fall? Unintentionally caught air Intentionally caught air Caught edge Lost edge/slipped out Crossed tips Caught tip Uncontrolled slide Uncontrolled slide stopped by object or person Landed feet first Fell backward Fell forward Fell to side Uncontrolled tumble Inverted/Upside Down Landed flat/on back or front Lost gear (skis/poles/goggles) Other What was the guest doing prior to the incident?*Examples: "They were skiing down the hill making wedge turns." Or, "They were standing still on the side of the run."Describe speed you observed the guest traveling if applicable*Faster than surrounding trafficSame speed as surrounding trafficSlower than surrounding trafficGuest was stationaryThere was no surrounding trafficDid not observe speedDid the guest make any comment to you before or after the incident?*YesNoDescribe comments made by guest*Describe actions of guest in terms of what they did and what you noticed.*Avoid describing what you think happened or attributing any cause in this narrative.How far away were you from injured student at time of incident?*Above StudentBelow StudentTo the Side of StudentList your actions following the incident* Stayed on scene until Ski Patrol arrived Called/Radioed/Sent for Patrol Called/Radioed/Contacted my Supervisor Provided scene safety (crossed skis, closed jump, stood uphill, etc.) Observed injured guest staying at point of rest Observed injured guest moving from point of rest Describe any specific action you took before, during and/or after the incident if needed*Was a lift involved in the incident?* No Yes Lift InvolvementName of Lift*Ballroom CarpetButtercupCascadeDaisyEasy RiderHeatherHood River ExpressMt. Hood ExpressShooting StarVista ExpressPosition of injured guest on lift*Single / AloneFar LeftFar RightCenterMiddle leftMiddle RightNumber of times on that lift today?*Name(s) of other lifts ridden that day (if any)Additional InformationAre you aware of any photos or video of the incident?*NoYesPlease list name and contact information for people in possession of photos or video*Did anyone make any statements to you concerning incident?*NoYesPerson's name making statement*Statement from person*Was Patrol called?*NoYesName of Patroller*If you did not get patroller's name, enter "unknown"Did student go to the Clinic / MES?*NoYesAdditional CommentsAdditional Instructor CommentsAvoid making comments that require conjecture, what you think happened, or attributing any cause in this narrative.Class Member NamesList names of additional class member(s)Supervisor Review* This has been reviewed with my supervisorI have completed this form with strictly factual information and have not included any information that is opinion. I have reviewed this content with my supervisor prior to submitting it.Signature*Your NameYour NameYour NameYour Name
