Carolina Mountain Club

CMC OM - Incident Report 2b

Carolina Mountain Club, Inc.

INCIDENT REPORT  

 PERSON COMPLETING REPORT: __________________________________________________________ 

 

SIGNATURE___________________________________________________________ DATE: ___________


ADDRESS: _____________________________________________________________________________ 


PHONES: (H) ____________________ (C)_______________________ (W)__________________________

 

CMC HIKE NUMBER AND/OR NAME_________________________________________________________

 

DATE OF INCIDENT: _______________ TIME: __________

 

LOCATION: _____________________________________________________________________________

 

DESCRIPTION OF INCIDENT: (PLEASE ATTACH ADDITIONAL PAGES AS NECESSARY) _____________

 

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PERSON CLAIMING INJURY OR DAMAGE 

 

NAME: ________________________________________________   PHONE: ________________________

 

ADDRESS: ______________________________________________________________________________

 

IF INJURY, DESCRIBE: ____________________________________________________________________

 

IF PROPERTY, DESCRIBE: ________________________________________________________________

 

TAKEN TO HOSPITAL? ________________ MEANS OF TRANSPORT: ____   DOCTOR?______________

 

WITNESSES:  

 

NAME: _______________________  ADDRESS: _________________________ PH: _________________ 

 

NAME: _______________________  ADDRESS: _________________________ PH: _________________ 

 

ANY GOV. OFFICIALS / EMS INVOLVED? ___________    TYPE:________________________________

 

ADDITIONAL COMMENTS, IF ANY ___________________________________________________________________

 

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After completing this form, please email a copy (or relevant information) to the current CMC President and then mail original to the Hike Scheduler as soon as possible.

                Approved CMC Council 9. 2018