KYC Incident Report

Need to report an incident, accident, or issue at the Kelowna Yacht Club?

Please, fill out the form below and your issue will be logged. If necessary, someone from the Kelowna Yacht Club will be in touch to discuss your report.

If possible, please include photos.

Non-Disclosure Agreement: All information and materials disclosed or provided under this submission, constitute Confidential Information regardless of when such information was provided.

What type of incident do you wish to report? *

• Health & Safety
• Environmental
• Maintenance

Date / Time of incident *

Date

Time

Approximate Location of Incident, Issue, or item needing maintenance? *

Was a KYC Member involved? *

• Yes
• No

Name of staff filling out report *

First

Last

Email of staff filling out this report *

Name of Injured Member, Guest, or Person from the General Public *

First

Last

Member Number *

1.) If the injured person is a guest of a member please denote the related Member Number. 2.) If a member reported the maintenance issue input the member number here. 3.) If you did not get the member number just input ‘N/A’.

Phone Number of Injured Person *

Email of Injured Person

Nature and description of Injury, Incident, Issue, or item needing maintenance? *

First Aider *

Type a description (eg: medic, staff, member, citizen) if you did not get a name.

Medical Treatment *

If first aid was provided, what materials did you use and from which first aid kit

Source of the spill *

Approximate size and quantity of spill *

Cause and impact of the spill *

Agencies / persons advised concerning the spill *

Were contaminated used materials disposed properly in the drums? *

• Yes
• No
• Unsure

Control measures taken or proposed *

How can the incident or issue be prevented from happening again? And/or measures to prevent other occurrences? *

Was the issue solved? *

• Yes
• No
• Not Sure

Upload applicable photo(s)

Click or drag files to this area to upload. You can upload up to 2 files.

Please include photos to assist in the Kelowna Yacht Club and their ability to assess and remedy and / or prevent the this incident.

Submit