Risk Assessment and Management

Day Walk – Adelaide Hills

Kuitpo Forest

Table of Contents
Risk Assessment and Management.................................................................................................................................7
Context Establishment................................................................................................................................................8
Risk Identification........................................................................................................................................................9
Risk Analysis and Management Strategy...................................................................................................................10
Dynamic Risk Assessment Framework......................................................................................................................21
Emergency Management Planning Details................................................................................................................22
Planning.................................................................................................................................................................22
Preparation............................................................................................................................................................22
Response...............................................................................................................................................................22
Recovery................................................................................................................................................................23
Incident and Emergency Response Plans..................................................................................................................23
Accident Report Form...............................................................................................................................................24
Emergency – Serious Incident Form..........................................................................................................................25

1
Context Establishment
Activity

Type Single day bushwalk and orienteering

Purpose of activity Build an understanding of walking longer distances and requirements
associated such as

 Plan and prep

 Equipment including clothing, food, water, etc…
 Technical capabilities including navigation and timing
 Essential capabilities such as leadership styles and debriefing
Date and time 8.45am – 4pm

Wednesday 15th July

Friday 17th July

Participant
Participants (number and group) 30 participants plus 2 Instructors as 2 separate groups (1:22 for day walks
with adults - AAAS)

Experience Mixed experience – students studying sport or PE so generally a level of

fitness identified
Restrictions See medical summary sheet collated from FlinSafe

Health and wellbeing See medical summary sheet collated from FlinSafe
Gender considerations None known – all above age of 18

Cultural considerations None known

Environment

Location (s) Kuitpo Forest

Climate and weather
Conditions will be varied during these days and therefore weather
information will be included in information packages and participants are
required to also gather this information as part of their leadership
preparation. Generally these areas experience mild to cold conditions and
some rain is likely during this time of year. Instructors must make sound
judgements relating to weather and hail or lightning must force a
cancellation of activity. As this area is governed by forestry fire warnings
and logging closures will also be considered and may result in location
change or cancellation.

Sustainability  Apply leave no trace principles in all locations

Land owner / manager requirements
 National parks guidelines for conservation parks applied even though
officially forestry are (Kyeema is recognised conservation park)
 Apply considerations for Phytophthora – cleaning principles on shoes
and equipment that contacts soil.
 Use identified paths only
 Not to proceed on catastrophic fire danger – check parks advice on
extreme fire danger.
2

Leadership
Roles and responsibilities
Competencies required
Supervision
Logistics and equipment
 No permits as this is part of an educational experience rather than as a
tour operator.
 Abide by ratio recommendations (AAAS) of 1:22
 Minimum day walk leader required as tracks are class 1-2
 Leaders of each group to enact duty of care and align with roles
outlined in leader prep package.
 Leaders are to make sound and informed judgement within their
qualification or equivalent recognition of experience.
 Students and Leaders to complete FlinSafe agreement and abide by
this.
 Day walk leader or equivalent
 Abide by ratio recommendations (AAAS) of 1:22
 While orienteering outer boundaries are set, must always work in pairs
with a phone
 If lost, head west to Brookman Road

Equipment Outlined in information pack

Logistics Outlined in information pack

Communications Outlined in information pack

 Phones (leaders and students)

Has anything been identified from a previous relevant experience?

 For 2020 corona virus procedures have been included

What action has been taken?

 For 2020 corona virus procedures have been included

 Completion of AAAS guidelines have reshaped the risk planning documentation

Risk Identification
Risks (list of possible events where an accident, injury or loss could occur)

1. Motor vehicle accident 2. Exposure to elements 3. Heat stress / dehydration

including development of
hypothermia or
hyperthermia
4. Inadequate nutrition or 5. infection, gastro, etc… 6. Medical emergency
hydration
7. Physical Injuries 8. Manual handling 9. Bites and stings
10. Sun burn 11. Natural disaster 12. Split group or lost participant
13. Anxiety 14. Exposure to a virus 15.

Now transfer to below and identify for each risk, the risk factors under categories of:

 (P) People (leaders and participants)

 (En) Environment
 (EL) Equipment and Logistics
3
Then complete

 Assessment of risk
 Identification of management strategies
 Implementation of risk management

4
Risk Analysis and Management Strategy
Risk Calculation Matrix
Consequence

Insignificant (I) Minor (mi) Moderate (Mo) Major (MA) Catastrophic (C)
Almost Certain (A) High (H) High (H) Extreme (E) Extreme (E) Extreme (E)

Probability Likely (L) Medium (M) High (H) High (H) Extreme (E) Extreme (E)
Possible (P) Low (L) Medium (M) High (H) High (H) Extreme (E)

Unlikely (U) Low (L) Low (L) Medium (M) High (H) High (H)
Rare (R) Low (L) Low (L) Medium (M) Medium (M) High (H)

Risk Calculation Matrix Descriptors

Probability of Risk Factors (P) Consequence of Risk Factors (C)

Almost Certain (A) Expected to occur in most circumstances; and/or high level of Insignificant (I) no injury or fatality; first aid not required
recorded instances
Likely (L) Will probably occur in most circumstances; and/or regular Minor (mi) injury requiring first aid and able to continue
recorded instances

Possible (P) might occur at some time; and/or few, infrequent, random Moderate (Mo) injury requiring medical treatment, possibly some hospitalisation
recorded incidents and/or unable to continue
Unlikely (U) not expected to occur; and/or no recorded incidents Major (MA) extensive injuries requiring significant hospitalisation

Rare (R) may only occur in exceptional circumstances Catastrophic (C) fatality, possible threat to life or severe injuries causing permanent
disablement

*NOTE: specific location information to be highlighted

Kuitpo Forest

5
6
Obtain From Risk Factor Risk Analysis Risk Management
Identification
Risk RF P C Ris Comments on Risk Management Strategy Resources Required Residual Communication
k Risk Required
Lev
el

1 - Motor 1 - fatigue U C H Driving is not within  Appropriate licences  Participant R MA Leaders to

vehicle the timeframe of the  Locations within 1.5 hour of information discuss vehicle
Adelaide package M
accident (P) field trip as logistics prior
participants will  Finish time is prior to dark including maps to departure
1 – reckless U C H meet at and leave  Appropriate licences R MA
driving from the identified  Provide location information prior
M
location, however  Must obey road rules
1 - Motor 1 – hazards on U MA H they will be informed  Appropriate licences R MA
vehicle the road of the risks  Must obey road rules
M
accident (En) associated, and be
provided with
1 - Motor 1 – unclear R I L  Appropriate licences RI
location information.
vehicle route  Clarify routes between leaders
L
accident (EL) before departure
 Info packs

2 - Exposure 2 – incorrect P Mo H Students undertake  Participant info books  First aid kits R Mi Info in prep
to elements information to preparation  Participants required to access including workshop
weather emergency L
including participants workshops and are
development including required to access  Equipment checked prior to blankets
of weather details weather information departure  Equipment lists
hypothermia themselves. to leaders and
participants
or Weather info is also
hyperthermia provided in
(P) information
packages. A packing
2– U Mo M  Maintain ratios R Mo
list will assist with
inappropriate  Constant supervision of group while
preparation – M
walking
7
 supervision leaders should check  Lost procedures identified for
that appropriate orienteering
clothing is worn and  Appropriate management strategies
equipment has been such as markers
packed prior to  If lost stay by the track or head west
commencing to brookman road and send a text
message to leader and group
members
2 - Exposure 2 – weather P Mo H  Participant handbooks R Mi
to elements conditions and  Inform of weather access in prep
days prior to walk L
including changing
development weather  Check equipment pre departure
of  Thermal blanket in first aid kit
hypothermia  Exits identified and easily accessible
or
hyperthermia
(En)

2 - Exposure 2 – broken, P Mo H  Equipment check prior to departure R Mi

to elements missing or  Exits identified and easily accessible
L
including inappropriate
development equipment or
of clothing
hypothermia
or
hyperthermia
(EL)
3 - Heat stress 3 – incorrect U Mo M We are in metro  Info packs to students advising 2L  Equipment list in R Mi
/ dehydration information locations and can minimum information
package with L Info in prep
(P) from leader exit activity easily if
advice on water workshop
needed
3 – insufficient U Mo M  Info packs to students advising 2L R Mi
water or minimum
 Monitor intake throughout the day L
equipment
packed

8
3 - Heat stress 3 – high U Mo M  Check weather prior to departure U Mi
/ dehydration temperature  Appropriate clothing including hats
 Exit if needed L
(En)
3 – lack of L Mo H  Info packs to students advising 2L of U Mi
shade water minimum
 Monitor drinking L
 Appropriate clothing to be packed
including hat
 Seek shade where available – exit if
needed
3 - Heat stress 3 – insufficient U Mi M  Info packs to students advising 2L of R Mi
/ dehydration access to water water / day minimum
 Monitor intake throughout the day L
(EL)
4- 4 – incorrect R Mi L Prior workshop with  Easy exit is possible  Suggested food RI Info in prep
Inadequate information info provided and water in workshop
information L
nutrition or from leader
hydration (P) package
We are in metro Procedures for
4 – illness U Mi L  Students able to notify leader R Mi
locations and can missing
 No attendance if unwell
exit activity easily if  Easy exit is possible L sessions due to
needed illness
4 – lack of R Mi L  eating as a group to make RI
observation monitoring easier for leader
 pre check food before departure L
from leader

4- 4– R Mi L  Check weather prior to departure – RI

Inadequate temperature adjusted schedule above 30 degree
celcius L
nutrition or requiring
hydration (En) increased  Info packs to students advising 2L of
intake water / day minimum
 Easy exit is possible
4- 4 - insufficient R Mi L  Info packs to students advising 2L of RI
Inadequate access to water water / day minimum
 Easy exit is possible L
nutrition or
hydration (EL)
9
5 - infection, 5 – poor R Mi L As these are single  Sanitiser in first aid kit  Hand sanitiser in R Mi Discuss with
gastro, etc… hygiene day trips it is unlikely  Info provided on toileting bag students in pre
 Hand washing or sanitising prior to L
(P) practices that these will departure ws
develop. Students eating
5 - infection, 5 – contact U Mi L may not attend if ill  Encourage safe food practises R Mi
gastro, etc… with dirty and make alternate including bringing hand sanitiser
L
(En) surfaces, etc… arrangements
5 - infection, 5 – off food or U Mi L  Prior departure information to R Mi
gastro, etc… uncooked indicate safe practices with meat.
 Meets needing refrigeration not to L
(EL) meats
be brought
6 - Medical 6 – specific P MA H Medical information  Medical summaries to leader  First aid kit R MA Discuss with
emergency medical collected prior,  Check specific or unknown details complying with students in pre
with participants AAAS guidelines M
(pre-existing) conditions personal medication departure ws
(P) to be checked and  Personal medication to be carried  Personal first aid
discussed with  1st aid kits to follow AAAS standards and medication
leader prior to  Easy exit is possible  Medical forms
Communication
6 – food P MA H departure.  Medical summaries to leader R MA
of flinsafe
packed that  Check specific or unknown details
with participants M
could initiate
allergic  Personal medication to be carried
 1st aid kits to follow AAAS standards Communication
reaction
 Easy exit is possible with all leaders
 Allergy information shared with
group where necessary eg. Food
allergies not to bring
6 – low level of P Mi M  Group to check route plan R Mi
fitness  Injuries to be cleared with medical
practitioner prior to departure L
 Group to move as fast as slowest
participant
 Plans easily adjusted to return to
cars sooner or pick students up
from Brookman Road
6 - Medical 6 - allergens P MA H  Medical summaries to leader R MA

10
emergency present  Check specific or unknown details M
with participants
(pre-existing)  Personal medication to be carried
(En)  1st aid kits to follow AAAS standards
 Easy exit is possible
 Allergy information shared with
group
6 - Medical 6 – route not U Mi L  Changes can be made easily R Mi
emergency appropriate for
L
fitness level
(pre-existing)
(EL)
6 – incorrect or U C H  Medication checked pre departure R MA
missing  Medical summaries to leader
M
medication or  Check specific or unknown details
preventative with participants
strategies  Personal medication to be carried
 1st aid kits to follow AAAS standards
 Easy exit is possible
 Allergy information shared with
group
7 – physical incorrect P MA H Instructors are to be  Operate within appropriate ratios  First aid kit R Mo Info packages
injuries (P) application of suitably qualified and scope of qualification complying with for info
 Prior briefings AAAS guidelines M
self- and apply sound
management judgement  Medical forms
associated with  Phones for
Tripping in pine U MA H  Operate within appropriate ratios communication R Mo
qualification
forest and scope of qualification  Info packages
 Remain on defined trails M
 Off track sections defined by
instructors
participant not U MA H  Expectations established R Mo
following  Flinsafe signed
 Pre departure info M
instruction or
ignoring  Operate within appropriate ratios
forestry and scope of qualification
11
 working signs  Ongoing monitoring
incorrect use P MA H  Operate within appropriate ratios R Mo
of equipment and scope of qualification
 Prior briefings to inform correct M
technique such as pack lifting and
monitor
 Establish working areas and
management techniques
7 – physical Unstable, P MA H  Appropriate walking shoes R Mo
injuries (En) uneven or  Instructor to monitor suitability of
track M
loose ground
 At water crossings establish most
slippery P MA H stable route R Mo
ground such as
M
after rain
7 – physical equipment U MA H  Check packs and footwear prior to R MA
injuries (EL) failure departure for suitability
M

Incorrect U MA H R MA
footwear
M
Route crossing U MA H  Observe information and reroute 
roads of signs
through
forestry
activity

8 - Manual lack of leaders U Mi L Adjustments for  Correct technique shown to bags  First aid kit R Mi
handling (P) instruction or existing injuries and monitored complying with
 Share carrying load AAAS guidelines L
observation

12
 participant U Mi L Share carrying  Medical forms R Mi
misbehaviour responsibilities
L
including not
listening
incorrect lifting P Mo H R Mi
or carrying
L

8 - Manual
handling (En)
8 - Manual weight of bags P Mo H U Mo
handling (EL)
M

9 - Bites and participants U Mo M First aid kit to follow  Stay in ratios  First aid kit R Mo  Discuss to
stings (P) not following AAAS suggestions  Clear leader instruction regarding complying with stay on
management techniques and AAAS guidelines M tracks and
leaders and be checked prior
instructions to departure operating boundaries  Medical forms in open
 Stay on tracks where possible and in  Info packs areas
operating boundaries
walking off P Mo H  Leader to monitor R Mo
track
M

9 - Bites and insect or spider P Mi M  Instruction on how to monitor U Mi

stings (En) bites and spiders
 Don’t lift rocks / bark / logs etc… L
strings
 Stay in designated areas
snake bites U MA H  Do not approach R MA
 Stay still if sited
M
 Remain on paths when available
 Stay as a group and in designated
areas
 Don’t lift rocks / bark / logs etc…

13
9 - Bites and incorrect U Mo M  Equipment check pre departure R Mo
stings (EL) footwear or  Info packs provided
M
clothing
10 – Sun burn not applying P Mo H First aid kit to follow  Slip, slop, slap, seek, slide  First aid kit R Mi Information in
(P) correct AAAS suggestions considered in equipment list and complying with pre departure
monitored. No participation if non- AAAS guidelines L
clothing or sun and be checked prior workshops
protection to departure. compliant  Medical forms
 Seek shade where possible  Info packs
10 – Sun burn over exposure P Mo H  Weather info R Mi
(En) to the sun
Weather information L
to be obtained prior
10 – Sun burn incorrect P Mo H R Mi
(EL) clothing or sun
L
protection
Info packs provided
extended time P Mo H to advise R Mi
in the sun
L

11 - Natural Students not R MA M Rules and  Pre departure information  First aid kit R Mi Weather
disaster (P) following expectations are set regarding expectations and complying with updates
consequences AAAS guidelines L
leader in pre departure discussed on
instruction workshops. Students  Weather checks by all  Medical forms day of
encouraged to ask  Info packs departure
Lack of R MA M  Pre departure info regarding R Mi
clarifying questions
information weather and natural disasters info
L
from leader

11 - Natural Bushfire R C H Weather information  Check weather information pre R MA

disaster (En) to always be gained departure
 Change plan on closure days M
and national parks
Thunderstorm R C H guidelines regarding  Check weather information pre R MA
closures followed departure
 Do not proceed during thunder M
 Exits are easily accessed
14
 Gale force R C H  Areas mostly protected R MA
winds  Exits are easily accessed
 Weather checks pre departure M
Falling trees or R C H  Check the area for dead trees and R MA
branches limbs to avoid
 Remain on track in naturally M
vegetated areas
11 - Natural incorrect or R MA M  Weather information to be checked R Mo
disaster (EL) absent pre departure
M
weather
information

12 - Split lack of R Mo M Maintain ratios  Maintain ratios  Information R Mi

group or lost appropriate Common leadership  Common leadership techniques to packages
be applied. L
participant(P) supervision techniques to be
applied.  Group briefed to remain where you
participant R Mo M are if split group on track or if off R Mi
misbehaviour track head west to Brookman road L
and text leader
Clearly identify
inadequate R Mo M  Never venture alone R Mi
working areas
leadership  Maps in info packs
 Rules and expectations set and L
techniques
agreed on pre departure
12 - Split unclear trail R Mo M R Mi
group or lost
L
participant
(En)

12 - Split incorrect R Mo M R Mi
group or lost participant
L
participant ratios
(EL)
13 – Anxiety inexperience P Mi M Monitor for signs  Pre departure workshops informing  Medical forms U Mi Development
(P) and prepare students  Info packs throughout the
 Information package supplied L
students for carried with exit sessions will
 Monitor for debrief
15
 uncomfortable P Mi M expectations in pre  Pre departure workshops informing points identified U Mi enable
toileting or departure workshop. students  Trowel and toilet students to also
 Information package supplied L
hygiene paper analyse
practices  Monitor for debrief situations and
As these are day  Take trowel and toilet paper build
period P Mi M U Mi
trips, adjustments knowledge that
can be made and L helps them
exits accessed easily understand the
history P Mi M  Pre departure workshops informing U Mi
options
students
L available to
 Information package supplied
them.
 Monitor for debrief
 Can be declared in medical
information
unknown P Mi M  Pre departure workshops informing U Mi
students
 Information package supplied L
 Monitor for debrief
13 – Anxiety extreme P Mi M  Pre departure workshops informing U Mi
(En) weather students
 Information package supplied L
 Check weather pre departure
 Monitor for debrief
13 – Anxiety Length of walk P Mi M  Pre departure workshops informing U Mi
(EL) students
 Information package supplied L
 Monitor for debrief
 Building knowledge throughout
 Identify exit strategies
14 – exposure hygiene P Mo H The federal and state  Students advised to shower before https://www.health. U Mo  New
to a virus (P) practices governments and after activity (at home gov.au/sites/default/ manageme
preferable) M nt
provide clear files/documents/202
guidelines for  Hand sanitiser must be brought 0/05/australian- guidelines
preventing the  Coughing/sneezing etc to be institute-of-sport- provided to
spread of corona directed away from others, into ais-framework-for- students
elbow and sanitising to be applied

16
 not applying P Mo H virus.  Checks to be done visually from rebooting-sport-in-a- U Mo  Communica
social 1.5m covid-19- tion about
 Physical distancing applied at all M current
distancing environment.pdf
COVID safe plan to times where safety is not covid safe
be provided and compromised practices
pre existing P Mo H
followed  Students enforced to stay home if U Mo
infection experiencing symptoms such as
fever, sore throat, common cold, M
COVID procedures
etc… checklist to be
high risk P Mo H  To be communicated with leader followed U Mo
category and in medical information and
medical professional advice to be M
followed
14 – exposure  Physical distancing to be applied on U Mo
to virus (En) tracks and at all rests
M

14 – exposure vehicles A Mo E  Self drive, limited car pooling and U Mo

to virus (EL) social distancing to apply
M
multiple A Mo E  the likelihood of community U Mo
people needed transmission is incredibly low.
Equipment will be minimised, M
for activity
however hygiene practices outlined
above will be applied.
Date Reviewed: 25/6/2020 Reviewed By: Joss

Next Review Due: 25/06/2021

17
Dynamic Risk Assessment Framework

(Australian Adventure Activity Standards 2019)

Was significant dynamic risk assessment conducted during this activity last year resulting in change?

No – the progression of learning enhanced the safety of participants

Detail people involved, situation, action and communication

Novices – pre departure communication and info books provided.

What needs to result in the next similar instance?

No changes required

18
Emergency Management Planning Details

Planning
 emergency response actions, allocated roles and responsibilities
o roles outlined in information pack and respones outlined below in incident and emergency plans
 closest available professional medical care (e.g. hospital, clinic, doctor)
o outlined in information pack
 contingency plans for foreseeable emergencies (e.g. injuries, fire, flood)
o walk west to Brookman Road, text leaders and wait for pick up
o multiple access points indicated in maps and route if evacuation needed
o dealing with injuries outlined below in incident and emergency response plans
 strategies relevant to the features of the area being visited
o outlined in risk identification

Preparation
 emergency access and escape routes (where possible)
o see route outlined in info pack
 assembly points where appropriate
o brookman road between HQ and Kyeema
 details of key organisations (e.g. ambulance, land manager, local police) and how to best contact them in an
emergency
o outlined in information pack
 communication equipment that will be used, including coverage notes and/or limitations (e.g. mobile phone,
satellite phone, radio)
o outlined in leaders information pack
 mobiles sufficient for locations
 relevant aspects of the land manager’s emergency strategy (e.g. gaining assess past locked gates)
o outlined in information pack
o no permits required for educational groups

Response
 the process or procedures for responding to an emergency
o outlined below in incident and emergency response plans
 the process or procedures to confirm or ensure the safety of a group that fails to return or check-in as planned
o outlined in flinsafe approvals
 the emergency trigger for a non-participating contact, to commence the planned process or procedures to
confirm the safety of the group and/or inform emergency services if the group fails to return or check-in
o outlined in flinsafe approvals
o leaders to identify Joss of completion by 4.30pm
o if no contact by 4.30pm, Joss to contact leaders
o if no contact by 5pm emergency services will be notified
o Joss notified as soon as possible of incident or emergency
 a strategy for maintaining appropriate participant supervision if the planned activity changes (e.g. an injured
leader is evacuated or escorting participants who are withdrawing from the activity)
o consult info pack and exit strategies
o ratios must be maintained
o follow check in procedures
o phone procedures outlines emergency response
 access to personal contact and medical information
o to be carried in hard copy by leaders
19
 o stored in flinsafe

Recovery
 reporting requirements for fatalities, serious injuries or illness and dangerous incidents
o outlined below in incident and emergency response plans

Incident and Emergency Response Plans

Incident

 Apply first aid if necessary and manage the group

 Keep record via incident report form below
 Contact university contact as soon as practical
 If exit is needed then exit according to info pack for location and contact student emergency contact to collect
 If no exit is needed reassess and continue if able to do so with group
 If collected reassess and continue if able to do so with remaining group
 If no option for collection, alter trip to exit to nearest vehicle
 Once practical incident report must be entered to Flinsafe and national UPLOADS project
 Review to be conducted with group and reassess risk assessment and management

Emergency

 Have students call emergency services from mobile 000 or 112 (follow incident report form included)
 Manage group (instructor 1 to identify safe location and allocate leader to monitor).
 apply first aid (leader in charge to administer or delegate to willing trained first aider)
 Debrief group to what is happening. Group members positioned to help identify casualty site for emergency
services.
 Prepare group and victim for evacuation via either air lift or identified exit location on the route outline
 Preserve site if major emergency or fatality where practical
 Evacuate group.
 Contact university contact and emergency contact as soon as practical
 Once practical incident report must be entered to Flinsafe and national UPLOADS project

 The effective management of any incident in the field will, for the most part rely on sound judgement and
decision making from the group leaders on the scene.
 University to be consulted regarding student and staff support and counselling that is available.

20
Accident Report Form

Date of Accident_____________ Time of Accident ________________

Student Involved ____________________________

Location of Accident ___________________________________

Nature of Injury

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Description of Accident

________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Action taken by staff member

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Name of witness or others present

_________________________________________________________________________

_________________________________________________________________________

Medical Referral ____________________________________________________________

Signature ________________________ Date _________________

Leader in Charge signature _______________________

21
Emergency – Serious Incident Form
(YOU MUST FILL IN THIS FORM FOR AN ACCIDENT THAT HAS CAUSED INJURY OR WHERE CONDITIONS REQUIRE
MEDICATION OR ONGOING TREATMENT)

Name (patient)……………………………………………………………..…………… Date………………………………

Summary - Emergency Services Contact Information

We require an ambulance. My name is………………………………… We are a University group. Our location

is…................................................................................................................................. ( grid reference and

description)

We have a casualty who is a ……………………..year old male/female whose Chief Compliant is:

……………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………......( symptom)

The patient states/witnesses state: (Mechanism of injury/History of present illness)

……………………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………………..
Observations patient found (describe position). Patient exam reveals (observation / injury). Vital Signs at (time).

Patient Exam

……………………………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………………..
Vital Signs

NORMAL 1 2 3 4 5 6
TIME
General
details
HR 50-100bpm
RR 12-20
(breaths/min)
SCTM PINK/WARM/DR
Y
TEMP 37 deg
22
HISTORY

Symptoms…………………………………………………………………………………………………………………………………………………………………….

Allergies……………………………………………………………………………………………………………………………………………………………………….

Medications………………………………………………………………………………………………………..……………………………………………………….

Pertinent medical history…………………………………………………………………………………………………………………………………………….

Last intake/output………………………………………………………………………………………………………………………………………………………

Events…………………………………………………………………………………………………………………………………………………………………………

ASSESSMENT (Problem list)………………………………………………………………………………………………………………………………………….

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PLAN (Plan for each problem on assessment sheet)……………………………………………………………………………………………………..

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ANTICIPATED PROBLEMS…………………………………………………………………………………………………………………………………………….

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*also complete incident report above to describe incident

*take and attach photos as soon as safe and possible

Notes

23