2025 Incident Reporting
The purpose of this Incident Report Form is to document all incidents that occur while serving or working with ACE. This form should be completed any time there is an incident of concern that you want ACE to be aware of, a near miss, an incident that may require future treatment or a possible worker's comp claim, or any incident that may need follow up at any given time. Please complete this form thoroughly and include as many details as possible.
Subject/Impacted Individual's Legal Name(s):
*
Please do not use nicknames or non-legal names
Subject/Impacted Individual's Position Title(s):
*
Subject/Impacted Individual's Service/Employment Status (not necessarily the person filling out the form):
*
Please Select
ACE Staff
Crew Member
Epic Member
Non-ACE
Is this a staff complaint, or a sensitive HR issue, instead of a physical/vehicle/social incident?
*
Yes
No
Instead of using the Incident Response form, use the ACE Complaint Form, which allows you to maintain greater privacy with who you email the form to (copy/paste into a new web browser):
https://drive.google.com/file/d/1zfUlvP-kCq_zspjssMMpB5JB04St23iz/view
Division/Department Reporting
*
Please Select
Crew PW
Crew MTW
Crew SWA
Crew SEN
EPIC USFS/BLM
EPIC FWS
EPIC NPS
Private Lands/NRCS
Org Finance/Tech
Org Culture
Org Hr
Org OOP
Org Central Program
Select the SWA staff member who will primarily support the management of the incident. Selected staff as well as division leadership will receive a copy of this IR.
*
Please Select
Kevin Schulze
Mary Aland
Jett Cattani
Bec Rosenblum
Jack McMullin
Keean Ruane
Claire Bolejack
Matt Park
Select the PW staff member who will primarily support the management of the incident. Selected staff as well as division leadership will receive a copy of this IR.
*
Please Select
Cassie Bongiorno
Devin Williams
Miyah Santos
Dawn Cramer
Carolyn Getschow
Carlee Koritkowski
Travis Reid
Nathan Schwarting
Tyler Lau
Dennis Frenier
Chris Binder
Jacob Brinker
Select the MTW staff member who will primarily support the management of the incident. Selected staff as well as division leadership will receive a copy of this IR
*
Please Select
Emily Gerberding
Patrick Sutherin
Scott Vlasak
Jessica Kervin
Keean Ruane
Select the SEN staff member who will primarily support the management of the incident. Selected staff as well as division leadership will receive a copy of this IR
*
Please Select
Amanda Gardner
Erin Canter
Nikki Jones
Joost Besijn
Kelcey Brown-Meacham
Lauren (Lolly) Martinek
Matthew Moore
Sarah Kachinovas
Rodolfo Falero
Witnesses (full names):
ACE Crew Leader or Supervisor Name(s):
*
Name of your ACE Point of Contact:
*
Project Name (ex's: Eldorado NF, Wildlife Monitoring; or Caliente NV, Trail Building):
Project Partner Agency
*
Please Select
US Forest Service
Bureau of Land Management
US Fish & Wildlife Service
National Park Service
Bureau of Reclamation
Natural Resource Conservation District
State/County
Non-Profit
Other
If Other, please specify
Incident Location (physical address or GPS coordinates):
*
Incident Date:
*
-
Month
-
Day
Year
Date
Incident Time:
*
Hour Minutes
AM
PM
AM/PM Option
Working/Serving Status
*
Please Select
During working hours
During "off" hours, but while on hitch
During non-working hours (day off)
Incident Type (select all that apply)
*
Illness
Injury/Assault/Extreme Weather/Evacuation
Near Miss
Vehicle
Social/HR/Behavioral/Judgement of Individual
Bite/Sting
Injury/Extreme Weather/Evacuation (select all that apply)
*
General Injury
Assault
Extreme Weather
Evacuation
Social/HR/Behavioral (select all that apply)
*
Near Miss
Family Emergency
Travel Problems
Safety/Judgement of Individual
Harassing Behavior
Discriminatory Behavior
Hostile Visitor Interaction
Theft
Property/Equipment Damage
Issue with Agency Partner
Issue with ACE Supervisor
Unprofessional Conduct
Psychological
Drugs/Alcohol/Tobacco
Witness to Traumatic Incident
Judgement of Individual
Type of Harassing Behavior
*
General Harassment
Sexual Harassment
Identity Based Harassment
Initial Incident Description Section
Incident Narrative (please describe events leading up to the incident and all details/facts of the incident as thoroughly as possible. Be thorough and objective):
*
Provide significant timeline details below:
-Date-
-Time-
-Event _____________________________________________
Witnesses
-
-
-
-
-
-
-
-
-
-
Do you anticipate losing one day or more of work (other than the day of injury) as a result of this workplace injury? Selecting no does not mean you aren't entitled to file for a worker's comp claim in the future.
*
Please Select
Yes
No
Illness
Type of Illness (select all that apply):
*
Abdominal
Anaphylaxis
Allergy, other
AMS (altitude)
Asthma
Cardiac
Covid-19
Dehydration
Exhaustion
Fever
Flu or Cold
Gastrointestinal
Other
Activity at the time of incident (select all that apply):
*
Hiking
Standing
Driving
Cooking
Hand tool use
Power tool use (excluding chainsaw)
Chainsaw
Swamping
Moving/gathering materials
Rock work
Rigging (ropes and pulleys)
Pesticide use
Tool maintenance
Cleaning
Vehicle maintenance
Field survey work
Other
Medications: Were medications administered?
*
Yes
No
Unknown
Date medication were administered:
-
Month
-
Day
Year
Date
Medication/drug name & quantity:
Problem being treated by administered medication:
Medication/drug administered by:
Injury, Extreme Weather & Evacuation Section
Type of Environment (select all that apply):
*
Base/Camp
Office
Warehouse
Housing
Canyon
Desert
Forest
Grassland
Lake
Mountain
Ocean
Road (paved)
Road (unpaved)
Urban
Rural
Meadow
Hills
River/Creek
Other
Surface condition:
*
Flat
Sloped
Trail
Off-trail
Wet
Dry
On/In water
Loose
Rock
Ice/Snow
Mud
Sand
Indoors
Other
Local conditions: Estimated Temperature (F)
Local conditions: Precipitation Type (select all that apply)
*
Rainy
Dry
Snowy
Clear
Cloudy
Foggy
Smokey/Hazy
Windy
Other
Local conditions: Estimated Wind
Please Select
None (no wind present)
Mild (slight breeze, under 10 mph)
Moderate (blowing light, unsecured items around, 10-30 mph)
Strong (blowing heavy, unsecured items around, or some poorly secured items, 30-50 mph)
Severe (blowing some well secured items around, 50+ mph)
Local conditions: Estimated Visibility (in feet; if more than a quarter mile, write "clear")
Local conditions: Estimated Altitude (in feet; write "unknown" if applicable)
Type of Injury (select all that apply):
*
Abdominal
Abrasion (scrape)
Anaphylaxis
Allergy, other
AMS (altitude)
Asthma
Blister
Burn
Cardiac
Cold Injury/Frostbite
Contusion (bruise)
Covid-19
Dehydration
Dental
Dislocation
Exhaustion
Fever
Flu or Cold
Fracture
Gastrointestinal
Other
Location(s) of Injury (select all that apply):
*
Head
Face
Eye (left)
Eye (right)
Mouth
Ear (left)
Ear (right)
Neck
Shoulder (left)
Shoulder (right)
Left Chest
Right Chest
Upper Back
Lower Back
Pelvis
Abdomen
Buttock
Genitalia
Upper Arm (left)
Upper Arm (right)
Elbow (left)
Elbow (right)
Forearm (left)
Forearm (right)
Wrist (left)
Wrist (right)
Hand (left)
Hand (right)
Finger (left)
Finger (right)
Upper leg (left)
Upper leg (right)
Knee (left)
Knee (right)
Lower leg (left)
Lower leg (right)
Ankle (left)
Ankle (right)
Foot (left)
Foot (right)
Toe (left)
Toe (right)
Other
Activity at the time of incident (select all that apply):
*
Hiking
Standing
Driving
Cooking
Hand tool use
Power tool use (excluding chainsaw)
Chainsaw
Swamping
Moving/gathering materials
Rock work
Rigging (ropes and pulleys)
Pesticide use
Tool maintenance
Cleaning
Vehicle maintenance
Field survey work
Other
Bloodborne Pathogens: Were body fluids spilled
*
Yes
No
Unknown
Bloodborne Pathogens: Was anyone exposed to body fluids that were not their own
*
Yes
No
Unknown
If Yes, were universal precautions followed?
*
Yes
No
Unknown
Medications: Were medications administered?
*
Yes
No
Unknown
Medications administration date:
-
Month
-
Day
Year
Date
Medication/drug name & quantity:
Problem being treated:
Medication/drug administered by:
Near Miss Incident Section
What were you doing (what was the activity)?
*
How did things not go as planned?
*
What could have been done differently?
*
Social/HR/Behavioral Section
Was this a one-time incident or has it been ongoing
*
Please Select
One-time
Ongoing
What activity was taking place at the time of the incident?
*
How did you react to the situation?
*
Did you take any action to stop the perceived inappropriate behavior (if yes, please describe)?
*
Describe the harm you have suffered as a result of the event (write N/A if not applicable)?
*
Was there anyone else involved in the incident (if yes, please describe who and how they were involved)?
*
Supporting evidence, if any (please describe, or attach documentation in the section below):
*
Has this incident been reported to others (please select all that apply)?
*
Another Member
ACE Staff (other than Crew Lead)
ACE Crew Lead
Partner/Agency Staff
Other
If you selected any of the above, please write names here if you are comfortable sharing:
*
Bites and Stings Section
Bites and Stings: Brief description of bite/sting location
*
Bites and Stings: Brief description of bite/sting reaction
*
Bites and Stings: Brief description of bite/sting treatment
*
Do you anticipate any loss of work time due to this incident, or the effected area getting significantly worse over time?
*
Please Select
Yes
No
Type of Environment (select all that apply):
*
Base/Camp
Office
Warehouse
Housing
Canyon
Desert
Forest
Grassland
Lake
Mountain
Ocean
Road (paved)
Road (unpaved)
Urban
Rural
Meadow
Hills
River/Creek
Other
Location(s) of Injury (select all that apply):
*
Head
Face
Eye (left)
Eye (right)
Mouth
Ear (left)
Ear (right)
Neck
Shoulder (left)
Shoulder (right)
Chest
Upper Back
Lower Back
Pelvis
Abdomen
Buttock
Genitalia
Upper Arm (left)
Upper Arm (right)
Elbow (left)
Elbow (right)
Forearm (left)
Forearm (right)
Wrist (left)
Wrist (right)
Hand (left)
Hand (right)
Finger (left)
Finger (right)
Upper leg (left)
Upper leg (right)
Knee (left)
Knee (right)
Lower leg (left)
Lower leg (right)
Ankle (left)
Ankle (right)
Foot (left)
Foot (right)
Toe (left)
Toe (right)
Other
Medications: Were medications administered?
*
Yes
No
Unknown
Medication administration date:
-
Month
-
Day
Year
Date
Medication/drug name & quantity:
Medication/drug administered by:
Vehicle Incidents Section
Driver Name (for primary ACE driver)
*
Driver Phone Number (for primary ACE driver)
Driver Email (for primary ACE driver)
Driver License Number (for primary ACE driver)
Vehicle ACE ID (i.e. P54)
Vehicle Year, Make and Model (for primary vehicle(s) driven by ACE occupant)
License Plate Number (for primary vehicle(s) driven by ACE occupant)
Full name of all vehicle occupants at time of incident (for primary ACE vehicle(s)
Description of known or visible vehicle damage (for primary vehicle(s) driven by ACE occupant)
Police report number, officer's name and phone number, or N/A if police not involved)
Were other vehicles involved?
*
Please Select
Yes
No
How many other vehicles were involved
Please Select
0
1
2
3
More than 3
Vehicle Year, Make and Model if additional vehicle(s) involved
License Plate if additional vehicle(s) involved
Additional Driver Name if additional vehicle(s) involved
Additional Driver License Number if additional vehicle(s) involved
Additional Driver Address if additional vehicle(s) involved
Additional Telephone Number if additional vehicle(s) involved
Additional Driver Insurance Provider and Policy Number if additional vehicle(s) involved
Description of known or visible vehicle damage if additional vehicle(s) involved
Witnesses Name
Witnesses Address
Witnesses Telephone Number
Additional Information to Collect for a Potential Worker's Comp Claim
The following are in reference to the injured individual unless otherwise noted
This section is only needed to help staff file a potential worker's compensation claim. If you are fairly certain this incident may lead to a worker's compensation claim (prolonged missed work/service due to an injury), please fill out as much of this information as you can (you can skip areas as needed). If you don't think this incident will lead to a worker's compensation claim, you can skip this entire section. If you have concern that circumstances may change, know that this information can be gathered at another time.
Subject/Impacted Individual Legal Name:
*
Please do not use nicknames or non-legal names
Date of Birth
-
Month
-
Day
Year
Date
Subject/Impacted Individual Sex:
Please Select
Male
Female
N/A
Subject/Impacted Individual Age:
Email
Address (current address of where the injured individual lives)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Marital Status
Term Start Date
-
Month
-
Day
Year
Date
Term End Date
-
Month
-
Day
Year
Date
Worker's Comp Class Code
Living Allowance (weekly) or Rate of Pay (hourly)
Has the employee already lost more than a full day of work time due to this injury?
Please Select
Yes
No
How much time has already been lost (in hours, other than the day of the injury)?
Does the employee expect to lose additional full-days of work after the submission of this IR?
Please Select
Yes
No
Has the employee lost any pay?
Please Select
Yes
No
Select start date when pay stopped
-
Month
-
Day
Year
Date
Select start date when pay started back up (if unknown, leave blank)
-
Month
-
Day
Year
Date
Do you anticipate this injury/condition getting worse?
Please Select
Yes
No
Is the injury related to a work activity?
Please Select
Yes
No
What is the Benefit State? (typically, the state the worker was hired in, or their "home base", will be the benefit state)
Additional Notes Specific to Worker's Comp:
Additional Information, File Uploads and Signature Section
Any additional information not on the IR specific to this accident that could be helpful in submitting a claim, or helpful in ACE’s post incident review:
If you have any additional documentation for this incident, including pictures, please upload here (not required, but especially important for vehicular incidents)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Name of person submitting this form:
*
First Name
Last Name
Date of form submission:
*
-
Month
-
Day
Year
Date
Person submitting this form is:
*
Please Select
ACE Staff
ACE Member
ACE Partner
Other
If you want a copy of this IR, please add your email here:
example@example.com
Submit
Should be Empty: