Hypothermia Incident Report Form
Use this form to document details of a hypothermia incident, including incident conditions, response, and recommendations. Title: Hypothermia Incident Report Form.
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
Location of Incident
*
Brief Description of Incident
*
Weather and Environmental Conditions
*
Number of Individuals Affected
*
Symptoms Observed
*
Shivering
Slurred speech
Clumsiness/loss of coordination
Confusion
Weak pulse
Other
Immediate Actions Taken
*
Equipment or Supplies Used
Follow-up Actions or Recommendations
Name of Person Completing Report
*
Submit Report
Should be Empty: