IWWF Incident Report Form

IWWF INCIDENT REPORT FORM

This form should be completed by the on-site Safety/Club Official or Event Organizer at the time of an Accident, Injury or Other Incident during An IWWF Sanctioned Event.
SANCTIONED EVENT INFORMATION:
Federation/Club/Event Organizer’s Name: Insert name*

Membership #:  Insert number*

Date(s) of Event: From*  To*

Address/Location of Event:

Street Address*   Address Line 2*   City*   State/Country*

  Zip*
Sanctioned Event Type: *

Competition Practice Exhibition Official’s Clinic Basic Skills Clinic Other
Total Number of Pulls / Tows (sets): *
Sport Discipline (please indicate applicable discipline): *

Waterski (3-Event) Cable Wakeboard Cable Ski Ski Racing Disabled Barefoot Wakeboard Wakesurf Show Ski Kneeboard
SUBJECTS INVOLVED (attach additional reports if more than one person was involved):
Name of Person Injured/Involved: *

First Name Middle Name Last Name
Nationality/Country: Country* Federation: Federation
Date of Birth: *

Day Month Year
Date
Gender: *

Male Female N/A
Email adress: *
example@example.com
Home Address: *

Street Address

Street Address Line 2

City State / Province/Country

Postal / Zip Code
Phone Number: *

Country Code Area Code Phone Number
Name of Parent/Legal Guardian (if minor):

First Name Middle Name Last Name
Phone Number:

Country Code Area Code Phone Number
Membership Status *

Active Other
Type of Individual: *

Athlete Official Coach Spectator Volunteer Other
Waiver Release *

Yes No
Please Attach Signed Waiver Release Form

Cancel of
Note: Signed waivers are required for all participants in sanctioned events
DESCRIPTION OF ACCIDENT/INCIDENT/INJURY/ILLNESS (check all that apply):
Type of Incident: *

Minor Injury or Illness Serious Injury or Illness Drowning Other Fatality Minor Property Damage Serious Property Damage Boating Accident Missing Person(s) Theft Other
Incident Location: *

Lake/Competition Area Restrooms/Lockers Premises/Grounds Bleachers/Stands Concession Area Admission Area Storage Area Parking Lot Other
Weather: *

Clear Clouds Rain Fog Glare Other
Water Conditions *

Calm Slight Chop Moderate Chop Rough
Wind Conditions *

None Light (1-6 mph) Moderate (7-14 mph) Strong (15-20 mph) Head Wind Cross Wind Tail Wind
Date and Time of Incident (12h time format - AM/PM) *

Day Month Year
Date
Hour Minutes AM/PM Option
Incident during Sanctioned Event? *

Yes No
Type of Event during which Incident/Injury occurred: Please specify*
Please answer the questions below and make use of the text blocks provided on this form to document additional details of this incident.
Safety Director on-site during the Event: *

Yes No
Were proper safety procedures and equipment utilized? *

Yes No
Were proper safety procedures and equipment utilized? *

Yes No
Name of Boat Driver *

First Name Last Name
Does the driver of the boat have an IWWF / National driver rating? *

Yes No
If so, what rating? Please specify
Police, DNR or Fire Department Notified: *

Yes No
Explain (autosizing text box, unlimited characters :
Any Witnesses to Incident/Injury: *

Yes No
- Name

First Name Last Name
Phone Number

Country Code Area Code Phone Number
- Name

First Name Last Name
Phone Number

Country Code Area Code Phone Number
First Aid Treatment rendered on-site: *

Yes No
Explain (autosizing text box, unlimited characters) :
Primary Medical Insurance Available: *

Yes No
If yes, Carrier and Policy #:
Photographs of Injury/Damage: *

Yes No
If yes, please attach to this form

Accepted formats: pdf, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancel of
REPORT PREPARED BY:
Name of Safety/Club Official or Event Organizer: *

First Name Middle Name Last Name
Phone Number

Country Code Area Code Phone Number
Email address
example@example.com
ADDITIONAL DETAILS OF ACCIDENT/INCIDENT/INJURY/ILLNESS:

(Note - text boxes below are auto-fitting and unlimited)
How did incident/injury occur? (Be specific - not simply “crash on jump")
Location and nature of injury or damage? (Describe as accurately as possible)
FIRST AID TREATMENT AND DISPOSITION:
First Aid Treatment rendered on-site: *

Yes No
Describe :
Was First Aid Treatment Refused? (Note signature requirements below if treatment refused) *

Yes No
Name AND Signature of INJURED PARTY

Name and Signature of injured party Clear
Name AND Signature of WITNESS

(Note: If Witness is a minor, obtain signature of the minor’s Parent/Guardian Clear
First Aid Disposition? (Check all that apply): *

Treated and released Transported to Hospital or Other Medical Care Facility
Method of Transport to Hospital or Other Medical Care Facility?

EMT/Ambulance Personal Vehicle Other
Name, Address and Telephone Number of Hospital or Other Medical Care Facility where transported?
Name of Hospital or Facility: Please specify
Address

Street Address

Street Address Line 2

City State / Province/Country

Postal / Zip Code
Phone Number

Country Code Area Code Phone Number
Should be Empty:

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IWWF INCIDENT REPORT FORM