Incident Report - Hornblower Cruises & Events

I. BASIC INFORMATION: Check all that apply

Location

Identify name / location

Date

Time

: HH

MM

Service / Route, if applicable:

Closest Shore-side Landing:

Person(s) Involved:

Employee
Passenger
Other

Area where incident occurred:

Name(s) of Those Involved: (First / Last)

INCIDENT SUMMARY

II. TYPE OF INCIDENT: Check all that apply

Type of Incident

Injury / Illness
Operations
Near-Miss

Injury / Illness

First Aid Offered, but DECLINED

First Aid Offered, but DECLINED

Operations

If Other:

Near-Miss

If Other:

Party(s) Involved

If Other:

III. INCIDENT DETAILS: Check all that apply

Location:

(Vessel, Shore-side, etc..)

Service / Route:

Physical Area:

Number of Passenger Onboard:

Type N/A if not applicable

Vessel

Body Part(s) Affected

Check all that apply (If, Applicable)

Head Area
Upper Body
Lower Body
Other

Head Area

Upper Body

Lower Body

Describe, if Other

Environment:

(Weather, Visibility, Physical Elements, Lighting, Vessel Traffic)

Weather

Wind Speed

Wind Direction

Temperature

Visibility

Poor
Moderate
Good
Excellent

Physical Elements

Lighting

Poor
Moderate
Good

Vessel Traffic

Light
Moderate
Heavy
N/A

IV. AFFECTED PARTY DETAILS:

Party Options

Party Refused to Provide Information
Party Refused Medical Attention
Party Requested Ambulance
Party Requested Copy of Incident Report

Name:

Contact Number:

Contact Email:

Home Address

Street Address City State ZIP Code

Date of Birth:

Gender

Male
Female
Undisclosed

Type of Footwear Worn:

If Other

Hospital location, if appl:

Requested Medical Treatment?

Yes
No
N/A

First Aid Administered?

Yes
No
N/A

By Whom?

(Print Name)

Witness to Incident?

Witness Name:

Withness Contact Number:

Witness Contact Email

V. ADDITIONAL DETAILS:

Captain

(Full Name)

Knowledge of Incident:

Yes
No