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:*

CompetitionPracticeExhibitionOfficial’s ClinicBasic Skills ClinicOther
Total Number of Pulls / Tows (sets): *
Sport Discipline (please indicate applicable discipline):*

Waterski (3-Event)Cable WakeboardCable SkiSki RacingDisabledBarefootWakeboardWakesurfShow SkiKneeboard
SUBJECTS INVOLVED (attach additional reports if more than one person was involved):
Name of Person Injured/Involved:*

First NameMiddle NameLast Name
Nationality/Country: Country* Federation: Federation
Date of Birth:*

DayMonthYear
Date
Gender:*

MaleFemaleN/A
Email adress:*
example@example.com
Home Address:*

Street Address

Street Address Line 2

CityState / Province/Country

Postal / Zip Code
Phone Number:*

Country CodeArea CodePhone Number
Name of Parent/Legal Guardian (if minor):

First NameMiddle NameLast Name
Phone Number:

Country CodeArea CodePhone Number
Membership Status*

ActiveOther
Type of Individual:*

AthleteOfficialCoachSpectatorVolunteerOther
Waiver Release*

YesNo
Please Attach Signed Waiver Release Form

Cancelof
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 IllnessSerious Injury or IllnessDrowningOther FatalityMinor Property DamageSerious Property DamageBoating AccidentMissing Person(s)TheftOther
Incident Location:*

Lake/Competition AreaRestrooms/LockersPremises/GroundsBleachers/StandsConcession AreaAdmission AreaStorage AreaParking LotOther
Weather:*

ClearCloudsRainFogGlareOther
Water Conditions*

CalmSlight ChopModerate ChopRough
Wind Conditions*

NoneLight (1-6 mph)Moderate (7-14 mph)Strong (15-20 mph)Head WindCross WindTail Wind
Date and Time of Incident (12h time format - AM/PM)*

DayMonthYear
Date
Hour MinutesAM/PM Option
Incident during Sanctioned Event?*

YesNo
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:*

YesNo
Were proper safety procedures and equipment utilized?*

YesNo
Were proper safety procedures and equipment utilized?*

YesNo
Name of Boat Driver*

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

YesNo
If so, what rating? Please specify
Police, DNR or Fire Department Notified:*

YesNo
Explain (autosizing text box, unlimited characters :
Any Witnesses to Incident/Injury:*

YesNo
- Name

First NameLast Name
Phone Number

Country CodeArea CodePhone Number
- Name

First NameLast Name
Phone Number

Country CodeArea CodePhone Number
First Aid Treatment rendered on-site:*

YesNo
Explain (autosizing text box, unlimited characters) :
Primary Medical Insurance Available:*

YesNo
If yes, Carrier and Policy #:
Photographs of Injury/Damage:*

YesNo
If yes, please attach to this form

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

First NameMiddle NameLast Name
Phone Number

Country CodeArea CodePhone 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:*

YesNo
Describe :
Was First Aid Treatment Refused? (Note signature requirements below if treatment refused)*

YesNo
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 releasedTransported to Hospital or Other Medical Care Facility
Method of Transport to Hospital or Other Medical Care Facility?

EMT/AmbulancePersonal VehicleOther
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

CityState / Province/Country

Postal / Zip Code
Phone Number

Country CodeArea CodePhone Number
Should be Empty:

IWWF INCIDENT REPORT FORM