Illness Injury Evacuation Report

Illness/Injury/Evacuation Report

Form for guides in the event of an illness, injury, or evacuation.

Trip Departure Date
MM slash DD slash YYYY
Trip Type
Guide #1 Name
Guide #2 Name
Time of Incident

: Hours

Minutes

AM/PM
Date of Incident*
MM slash DD slash YYYY
Location of Incident*
Name of Injured Person*
Mechanism of Injury/Illness
Events of Incident
Please describe the events leading up to the injury/illness and what proceeded
CHIEF COMPLAINT (OPQRST)
ONSET
Provokes
Quality
Region/Radiation
Severity
Time Sequence
Objective Data (SAMPLE)
Symptoms (Patient Exam)
Allergies
Medications/Drugs
Pertinent Medical History
Last Oral Intake/Output
Assessment: Prioritized Problem List
Vitals
Please include each recording's exact time and the vitals recorded.
Please sign below with your initials in acknowledgement that everything you have submitted and reported is correct and complete.*
Email
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