Cold Injury Incident Report Form
Use this form to document incidents involving cold-related injuries or exposure. Please provide as much detail as possible.
Reporter Full Name
*
First Name
Last Name
Reporter Contact Information (phone or email)
*
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Location (address or description)
*
Injured Person's Full Name
*
First Name
Last Name
Injured Person's Role or Affiliation
Describe the Incident
*
Type of Cold Injury or Exposure
*
Frostbite
Hypothermia
Chilblains
Trench Foot (Immersion Foot)
General Cold Exposure
Other
Body Parts Affected
*
Hands/Fingers
Feet/Toes
Face/Ears/Nose
Arms
Legs
Torso
Other
Observable Symptoms
*
Pale or waxy skin
Numbness or tingling
Shivering
Slurred speech
Confusion
Blisters
Swelling
Other
Environmental Conditions at Time of Incident
*
Freezing temperatures (below 0°C/32°F)
Windy
Wet conditions
Snow/Ice present
Prolonged exposure
Other
Immediate First Aid or Treatment Provided
*
Was Medical Attention Sought?
*
Yes
No
Unknown
Witness Names and Contact Information (if any)
Contributing Factors (e.g., inadequate clothing, equipment failure, fatigue)
Follow-up Actions or Recommendations
Submit Incident Report
Should be Empty: