Incident Database Sample Submission Form

This is a sample form designed to illustrate the major features of the International Incident Database Project. You'll see that the form is divided into numerous tabbed sections allowing you to enter a variety of data about a particular incident. Once the core incident data is entered and a specific IncidentID is generated by the database it is then possible to enter additional details which go into Child Tables of the core Incident Database. For example, you can enter details about People involved in the incident (core people data) into the People Table as well as specifics about their injuries or illnesses. The database connects the Person back to the Incident through the IncidentID field. Browse through the tabs and check out the range of data being collected. Many of the database lookup tables for items like Contributing Factors, Activity Type, etc. are populated with sample data for testing purposes. Additional items and definitions of concepts like Severity Level are part of the areas under discussion with product partners within the outdoor industry and will be added to and modified in the final release version.

Instructions

Please complete each section of the form by moving through each tab. Check your submission at the end and press the Submit Incident button. (This is a sample form. No data will be submitted)

General Incident Information
Tip Incident Category	--Select Category-- Close Call/Near Miss Incident
Type of Incident	--Select Incident Type-- Injury Illness Motivational/Behavioral Psychological Fatality Crime Harassment Sexual Contact Property Damage
Incident Event

Date & Time Information
Date Course Started*	March 2010   S M T W T F S 10 28 1 2 3 4 5 6 11 7 8 9 10 11 12 13 12 14 15 16 17 18 19 20 13 21 22 23 24 25 26 27 14 28 29 30 31 1 2 3 15 4 5 6 7 8 9 10
Incident Date*	March 2010   S M T W T F S 10 28 1 2 3 4 5 6 11 7 8 9 10 11 12 13 12 14 15 16 17 18 19 20 13 21 22 23 24 25 26 27 14 28 29 30 31 1 2 3 15 4 5 6 7 8 9 10
Incident Time of Day	Time Picker 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM
Total Days of Course*
Total Active Hours of Course*
Day Incident Occurred*

Course Information
Course Name	Enter the Course Name
Course Number	Enter the Course Number (numerals only)
Course Code	Enter Course Code (alphanumeric)
Participant Number	Enter the number of participants
Staff Number	Enter the number of staff
Total Number	Enter the total number on the program

Location Information
Country	--Select a Country-- Not Selected Argentina Australia Austria Bahamas Belgium Bolivia Brazil Canada Chile China Colombia Costa Rica Croatia Cuba Czech, Rep. Denmark Dominican Republic Ecuador Egypt El Salvador Finland France Germany Greece Guatemala Honduras Hong Kong Iceland India Ireland Israel Italy Jamaica Japan Luxembourg Mexico Morocco Netherlands New Zealand Nicaragua Nigeria Norway Other... Paraguay Peru Poland Portugal Puerto Rico Russia Saudi Arabia Slovenia South Africa Spain Sweden Switzerland Taiwan Thailand Turkey United Kingdom United States Uruguay Venezuela
Province	Enter the state or province where the incident took place
Area	Enter the area where the incident took place
Location 1	Enter the location where the incident took place (ex. Dimple Rapid)
Location 2	Enter the specific location where the incident took place (ex. left shoreline)
Grid Reference	Enter the Grid Reference
Grid Type	--Select Grid Type-- None Latitude Longitude UTM Select the type of the Grid Reference
Map Datum	--Select Map Datum Type-- None Selected NAD87 NAD23 Select the type of Map Datum
Location Description	Enter a detailed description of the location

Activity & Environmental Information
Type of Activity*	--Select Activity-- Backpacking Bike Touring Biking - Mountain Biking (day only) Camping Canoeing Caving Cooking Cycling Dog sledding Glacier travel Hiking (no pack) Horseback riding Independent travel Initiative game Mountaineering Portage Rafting Rappelling River crossing River kayaking Rock climbing Ropes course Running Sailing Sea kayaking Service project Ski touring Skiing (Telemark, downhill) Snow/Ice Climbing Snowboarding Snowshoeing Solo Sportyak Swim/Dip Transportation Unaccompanied travel Urban Activity
Activity Details
Type of Environment(s)*	--Select Environment Type-- Cliff Desert Farm Forest Glacier Lake Mountain Ocean River Road Snow/Ice Suburban Urban (multiple selections permitted)
Environmental Condition(s)	--Select Environmental Conditions-- Dry Flat Ice Rock Sloped Snow Trail Uneven Water - Calm Water - Choppy Water - High Waves Water - Rapids Water - Rough Water - Swift Wet (multiple selections permitted)
Weather Conditions	--Select Weather Conditions-- Clear Rain Snow Sleet Lighting Fog Wind (multiple selections permitted)
Wind Speed	--Select Wind Speed-- Not Known 0 kph 1-6 kph 7-11 kph 12-19 kph 20-29 kph 30-39 kph 40-50 kph 51-62 kph 63-75 kph 76-87 kph 88-102 kph 103-117 kph >117 kph Select the Wind Speed

Property Damage
Damage Severity Level	--Select Damage Severity Level-- None Minor Cost Moderate Cost Major Cost Catastrophic Cost
Type of Damage	--Select Damage Type-- None Other Personal Equipment Program Equipment Vehicle (multiple selections permitted)
Damage Description

Causal Factors & Narrative
Potential Severity*	--Select Severity Level-- Not Known 1 - Minor 2 - Moderate 3 - Serious 4 - Severe 5 - Critical 6 - Unsurvivable
Contributing Factor(s)*	--Select Contributing Factors-- Altitude Animal Encounter Avalanche Carelessness Cold Exposure Cultural Misunderstanding Dehydration Equipment Exceeded ability Exhaustion Failure to follow instructions Fall on rock Fall on snow Fall/slip on trail Falling tree/branch Fitness/ability Hygiene - poor Immersion/submersion Inattention Inexperience Insect(s) Instruction Intoxication (alcohol/drugs) Lightning Loose Rock Misbehavior Missing/lost Not following instructions Overuse injury Plant poisoning/toxicity/contact Poor Judgment Preexisting medical condition Psychological issue Rock fall Screening - improper Sun Supervision - inadequate Technical system failure Technique - poor Unknown Visibility - poor Weather (multiple selections permitted)
Equipment Involved
Narrative*
Assessment /Treatment	Enter the incident assessment or treatment
Analysis	Enter the incident analysis
Prepared By
Preparer Position
Submit Date	(automatically entered by database)

Review/Follow-up
Reviewer Comment*
Reviewer
Reviewer Position
Review Date	March 2010   S M T W T F S 10 28 1 2 3 4 5 6 11 7 8 9 10 11 12 13 12 14 15 16 17 18 19 20 13 21 22 23 24 25 26 27 14 28 29 30 31 1 2 3 15 4 5 6 7 8 9 10

Entering People Information

Once you check your form and click the Submit button in Section 10 you will have entered all of the basic information for this incident. If specific people were involved, you will be given an opportunity to transfer to another page to enter information about the people directly involved in the incident.

On this Sample Form Click here to see the People Information Form

Instructions

1. Press Check Submission: Check your submission before entering. If you are missing required information, you will be prompted to enter data.
2. Press Submit Incident: If no error messages pop up, then press the Submit Incident button. You will be taken to a confirmation page showing your new submission. Only press the button once.