Incident Report Form

CDG Incident Reporting Submission Form

Please enter the following required* information to submit a report.
You may also enter additional information in the Extended Reporting section. Consult the Reporting Guidelines for further information on how to report an incident.

Required Information
	* Region
	* Location
	* Incident date

* Incident Title

* Description of Incident

Lessons learned

Contributory Factors
Please the following factors and estimate their impact on the cause or end result of the incident

Contributary Factor	Impact of contributary factor
	Unknown	Negligible	Minor	Major
Line management
Gas management
Equipment management
Equipment failure
Training
Medical
Planning
Procedural error
Cave environment
Weather
Other (Enter details below)

* Publish
By selecting "Yes" you are authorizing the CDG to publish the Incident Title, Description of Incident, Lessons learned and today's date on the CDG website.
By submitting any information you are authorizing the CDG to analyse the incident report in aggregation with other incident reports and to publish summary statistics in way whereby it is not possible to identify any personal information contained in this individual report.

Extended Reporting
The following information is optional. None of this information will be published with the incident report but will be used in aggregation with other incident reports to publish summary statistics in way whereby it is not possible to identify any personal information contained in this individual report.

Personal Information

Name Email

Was this a fatal accident?

Total number of people involved in the incident

Diver A Information

Name		CDG Membership?
Age (at the time)		Sex
Total Cave Dives		Dives in this cave/site
CDG Qualification
Other Cave Diving Agency Qualification
Open Water Diving Qualification

Diver B Information

Name		CDG Membership?
Age (at the time)		Sex
Total Cave Dives		Dives in this cave/site
CDG Qualification
Other Cave Diving Agency Qualification
Open Water Diving Qualification

Further information on other people involved

Any additional comments