CMC Incident, Illness, Injury and Near Miss Report Form

CMC 24 Hour Emergency Call Service (269) 384-1056 if you need to connect with staff emergencies in the field. Please complete this form as soon as reasonable following the incident. This google form is how you file your incident report. If you have taken notes on the paper copy or pdf, please enter them here so we have a digital file. This form is collected by CMC staff to compile data on our incidents and near misses in the field. Personal details and contact information is only used to follow-up as needed to fill in incomplete information or check on the well being of someone who left the field without a follow-up by the trip leader/instructor. The compiled data will be used to report on our incidents and near misses club-wide to inform better risk management, places we may need to increase training, and compare data to similar organizations. Thank you for your leadership and communication of this incident or near miss in the field.
  = required field
Type of Injury or Illness (choose multiple if applicable)
Location / Conditions present during incident / injury / illness (check all that apply)  
Immediate Cause   Check all that apply
Contributory Cause Check all that apply
Contributory Cause Check all that apply

Thank you for submitting this report. If you would like to contact Graham Ottley to share additional information please contact at graham@cmc.org.