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RCC Incident / Near Miss Form
Data Processing Notice; Richmond Canoe Club takes your privacy seriously. We will only use your personal data to administer the incident report. All data you input here is also sent securely to relevant third parties only for the purpose of investigating the incident. We will only retain your personal data for as long as it takes for the incident to be resolved. At this point it will be deleted. External authorities may retain it longer for legal purposes.
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* Indicates required question
Email
*
Your email
Near miss or incident?
Near Miss i.e.: someone was nearly hit by a rower or had a potentially dangerous capsize
Incident i.e.: someone was injured, got hypothermia, was hit by a rower
First Name
Your answer
Last Name
Your answer
What is your email?
Your answer
What is your phone number?
Your answer
Are you a member of Richmond Canoe Club?
Yes
No
Clear selection
What was your role or connection with the incident?
Paddle Leader/Assistant Leader
Club Coach
Paddler Group Member
Event Organiser
Club official /Committee member
Race Competitor
Other River User
General Public
When did this incident / near miss happen?
MM
/
DD
/
YYYY
Where was the incident / near miss
Your answer
Incident Type - Please choose the most relevant description
Injury - was someone injured?
Medical Condition - did someone have a threatening medical condition i.e. hypothermia?
Other River/Water User - did someone collide with another vessel i.e. rower/motorboat
Access/Navigation - did a landowner or other confront you?
Angling Dispute - was there a confrontation with an angler?
Environmental/Pollution/Wildlife - did someone affected?
Emergency Service/Third Party Call Out - did they have to be called to the scene?
Other*
If 'Other' incident type
Your answer
Did the incident require medical treatment - Please choose all that apply *
Yes – via an onsite first aider/paramedic
Yes – attended A&E (not admitted to hospital)
Yes – admitted to hospital for less than 24 hrs
Yes – admitted to hospital for more than 24 hrs
Other*
If 'Other' medical treatment
Your answer
Who was involved? (Names if possible)
Your answer
Please describe the near miss or incident. Include here any relevant conditions such as weather, temperature, grade of white water, sea/river conditions etc.
Your answer
What was the final outcome of the incident or near miss? (If known)
Your answer
What can be learnt from this incident?
Your answer
A copy of your responses will be emailed to the address you provided.
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