AMI

Name First Last
Enter the contact information of the individual reporting the incident / accident here.
Phone Number ### - ### - ####
Email
General Information

In this section please complete the general information about the accident and primary individuals involved.
Type of Report
Accident (required medical treatment) Incident (no medical treatment)

If you had to do an medical assessment on an individual, it should be categorized as an accident. If there was an increase in risk, loss of gear or anything out of the ordinary, please indicate it as an incident.
Date MM / DD / YYYY
Date accident occured
Time HH : MM : SS AM/PM
Approximate time of day of the accident
Location of accident / incident

Please state the location of the accident, including the cliff, route and pitch, or any other information such as trail that is relevant to this report.
Name of primary individual involved First Last
Names of individuals involved will remain confidential. The name is for contact purposes only for clarification of information.
Phone Number ### - ### - ####
Optional. Please ask for permission to contact the individual. Omit if the individual does on wish to be contacted.
Age

Give the approximate age of the individual.
Year experience

Note approximate years climbing experience of the individual.
Brief description of climbing party

Please give a brief description of any relative information regarding the climbing party. Please include the number of people, familiarity with the location, level of experience for the group, equipment issues such as lack of rain gear or extra rope. Only include relevant information.
Name of secondary individual involved First Last
Names of individuals involved will remain confidential. The name is for contact purposes only for clarification of information.
Phone Number ### - ### - ####
Age
Year climbing experience

Note the approximate years climbing experience of individual.
Narrative of accident

In this section you will be writing a narrative of the scene and the sequence of events. Please get witnesses to describe what they saw and testimony of the individuals involved if possible.
Scene description

Please describe the scene leading up to the accident. Include conditions such as excessive heat, rain, cold, crowded. Include any information deemed relevant to this report.
Narrative of Sequence of Events

Please write a narrative of the sequence of events that lead up to the accident. Be objective and avoid any blame in the description. Simple state the events as they unfolded to the best of your ability.
Description of any injures or complants

Please list any symptoms that the person was complaining about or you observed.
Describe any treatments adminstered

Please indicate any treatments that were administered and any medical supplies or medicines used. If they decline treatment please notes this.
Witnesses

List any witness who would be willing to confirms these events.
Name First Last
Phone Number ### - ### - ####
Name First Last
Phone Number ### - ### - ####
Do Not Fill This Out

AMI

General Information

Narrative of accident

Witnesses