ASF CAVE ACCIDENT / INCIDENT REPORT FORM               Version: May 2001
 
                           INSTRUCTIONS
> To enter information on lines set your editor to 'overtype' and type 
  in the line regions. 
> To enter information in the [___] regions place an X like so [_X_]
> This form is 72 characters wide. To print use a fixed width font such 
  as Courier. 

Your name: _____________________________________________________________
Your ASF affiliation: __________________________________________________
Today's date: __/__/____  Date of incident: __/__/____ 
Address: _______________________________________________________________
         _______________________________________________________________
Phone:   ____________________ (h)   ____________________ (w) 

Please mark with an 'X' as many boxes as required for the following
questions:

Source of information: 		Contributing factors:
I am the: victim     [___]      gear failure    [___]
          witness    [___]      unsafe practice [___]
          rescuer    [___]      bad luck        [___]
          uninvolved [___]      inexperience    [___]

Injuries sustained:
none               [___] 	hospitalisation required [___]
minor              [___] 	very serious             [___]
first aid required [___]    fatal                    [___]

Number of persons injured [_____]

If known please supply a brief description of the injuries.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

If rescue was required how was it undertaken ?
Self rescue: [___]  	Assistance req.  (unofficial)   [___]
Assistance required (Police/Official Rescue Group etc.) [___]

Cave Description
Name and tag number (if known) or physical location (if known).
________________________________________________________________________
________________________________________________________________________ 						
Wet (deep standing pool or running stream)                       [___]
Dry ( no water or slight seepage and shallow water only)         [___]
Horizontal: under 200m [___]             over 200m [___]
Vertical:   pitches less than 30m [___]  pitches longer than 30m [___]

Party description:
Size of group:  1 - 4 [___]     4 - 10 [___]     11 plus [___]
ASF affiliated group  [___]     Non-ASF group [___]
* Please supply details here (if known):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Has the incident been written up in a journal/circular/letter etc? ____
If so please supply references here:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Please supply any further details that you consider relevant.
Also if available please mail copies of referenced articles.

When this form is completed please email to:
National Cave Rescue Commission Convenor, Ross Anderson 
email: rossjay@iinet.net.au 
or print out and mail to:
Australian Speleological Federation Inc., PO BOX 388, BROADWAY, NSW 2007

Thank you for your assistance and cooperation.