2025 Incident Reporting

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): *
Is this a staff complaint, or a sensitive HR issue, instead of a physical/vehicle/social incident?*

YesNo
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*
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. *
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.*
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*
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 *
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*
If Other, please specify
Incident Location (physical address or GPS coordinates): *
Incident Date:*

MonthDayYear
Date
Incident Time:*

Hour Minutes

AM/PM Option
Working/Serving Status*
Incident Type (select all that apply)*

IllnessInjury/Assault/Extreme Weather/EvacuationNear MissVehicleSocial/HR/Behavioral/Judgement of IndividualBite/Sting
Injury/Extreme Weather/Evacuation (select all that apply)*

General InjuryAssaultExtreme WeatherEvacuation
Social/HR/Behavioral (select all that apply)*

Near MissFamily EmergencyTravel ProblemsSafety/Judgement of IndividualHarassing BehaviorDiscriminatory BehaviorHostile Visitor InteractionTheftProperty/Equipment DamageIssue with Agency PartnerIssue with ACE SupervisorUnprofessional ConductPsychologicalDrugs/Alcohol/TobaccoWitness to Traumatic IncidentJudgement of Individual
Type of Harassing Behavior*

General HarassmentSexual HarassmentIdentity 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):*

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. *
Illness
Type of Illness (select all that apply):*

AbdominalAnaphylaxisAllergy, otherAMS (altitude)AsthmaCardiacCovid-19DehydrationExhaustionFeverFlu or ColdGastrointestinalOther
Activity at the time of incident (select all that apply):*

HikingStandingDrivingCookingHand tool usePower tool use (excluding chainsaw)ChainsawSwampingMoving/gathering materialsRock workRigging (ropes and pulleys)Pesticide useTool maintenanceCleaningVehicle maintenanceField survey workOther
Medications: Were medications administered?*

YesNoUnknown
Date medication were administered:

MonthDayYear
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/CampOfficeWarehouseHousingCanyonDesertForestGrasslandLakeMountainOceanRoad (paved)Road (unpaved)UrbanRuralMeadowHillsRiver/CreekOther
Surface condition:*

FlatSlopedTrailOff-trailWetDryOn/In waterLooseRockIce/SnowMudSandIndoorsOther
Local conditions: Estimated Temperature (F)
Local conditions: Precipitation Type (select all that apply)*

RainyDrySnowyClearCloudyFoggySmokey/HazyWindyOther
Local conditions: Estimated Wind
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):*

AbdominalAbrasion (scrape)AnaphylaxisAllergy, otherAMS (altitude)AsthmaBlisterBurnCardiacCold Injury/FrostbiteContusion (bruise)Covid-19DehydrationDentalDislocationExhaustionFeverFlu or ColdFractureGastrointestinalOther
Location(s) of Injury (select all that apply):*

HeadFaceEye (left)Eye (right)MouthEar (left)Ear (right)NeckShoulder (left)Shoulder (right)Left ChestRight ChestUpper BackLower BackPelvisAbdomenButtockGenitaliaUpper 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):*

HikingStandingDrivingCookingHand tool usePower tool use (excluding chainsaw)ChainsawSwampingMoving/gathering materialsRock workRigging (ropes and pulleys)Pesticide useTool maintenanceCleaningVehicle maintenanceField survey workOther
Bloodborne Pathogens: Were body fluids spilled*

YesNoUnknown
Bloodborne Pathogens: Was anyone exposed to body fluids that were not their own*

YesNoUnknown
If Yes, were universal precautions followed?*

YesNoUnknown
Medications: Were medications administered?*

YesNoUnknown
Medications administration date:

MonthDayYear
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*
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 MemberACE Staff (other than Crew Lead)ACE Crew LeadPartner/Agency StaffOther
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? *
Type of Environment (select all that apply):*

Base/CampOfficeWarehouseHousingCanyonDesertForestGrasslandLakeMountainOceanRoad (paved)Road (unpaved)UrbanRuralMeadowHillsRiver/CreekOther
Location(s) of Injury (select all that apply):*

HeadFaceEye (left)Eye (right)MouthEar (left)Ear (right)NeckShoulder (left)Shoulder (right)ChestUpper BackLower BackPelvisAbdomenButtockGenitaliaUpper 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?*

YesNoUnknown
Medication administration date:

MonthDayYear
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? *
How many other vehicles were involved
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

MonthDayYear
Date
Subject/Impacted Individual Sex:
Subject/Impacted Individual Age:
Email
Address (current address of where the injured individual lives)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Marital Status
Term Start Date

MonthDayYear
Date
Term End Date

MonthDayYear
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?
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?
Has the employee lost any pay?
Select start date when pay stopped

MonthDayYear
Date
Select start date when pay started back up (if unknown, leave blank)

MonthDayYear
Date
Do you anticipate this injury/condition getting worse?
Is the injury related to a work activity?
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)

Cancelof
Name of person submitting this form:*

First NameLast Name
Date of form submission: *

MonthDayYear
Date
Person submitting this form is: *
If you want a copy of this IR, please add your email here:
example@example.com
Should be Empty:

	-Date-	-Time-	-Event _____________________________________________	Witnesses
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2025 Incident Reporting

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):

Initial Incident Description Section

Illness

Injury, Extreme Weather & Evacuation Section

Near Miss Incident Section

Social/HR/Behavioral Section

Bites and Stings Section

Vehicle Incidents Section

Additional Information to Collect for a Potential Worker's Comp Claim

Additional Information, File Uploads and Signature Section