CDF Incident Analysis Project - Incident Submission Form

CDF Incident Reporting and Analysis Project Submission Form
Please enter the following required* Incident Report information. You may submit only the required data, or you may continue on to the additional optional fields. The optional fields allow you to provide more detailed information about the incident you are reporting. Not all incident reports need to be based on a narrative: More Information

Required Information

	Cave System*
	Location in System*
	Incident Date*
	Incident Time*

Incident Title*

Narrative* (You must enter something here, even if not intended for public Viewing)

PublishYesNo
By selecting "Yes" you are authorizing CDS to publish the Incident Title, Incident Narrative and today's date on the CDF IRAP pages.

Optional Information
The following information is completely optional. None of the these fields will be published with the incident report. These fields will only be used for incident analysis. Input any fields you wish, and only those fields that are relevant.
If you enter your email and/or name it will be kept completely confidential.

Reporting Diver Information

Name		Email
Age		Gender
Total Cave Dives		Dives in System
Position in Team

Training

NSS CDS	Cavern	Intro	Apprentice	Full
NACD	Cavern	Intro	Cave
GUE	Cave 1	Cave 2	Cave 3
TDI	Cavern	Intro	Cave
IANTD	Cavern	Intro	Cave	Tech Cave
CDG	Probationary	Trainee	Qualified
Other Cave/Cavern
Technical
Nitrox	Adv Nirox	Ext Range	Trimix
Open Water
OW	AOW	Rescue	Master
Divemaster	Instructor

Other Certifications

General Information
Max Depth		Max Penetration
Dive Stage
Team Size		Configuration
Mix(s)
	Stages
Incident Severity	1 2 3 4 5		(5 = near fatal)

Incident Factors
Please select a value (zero being a non-factor and five being a critical factor) indicating the relative importance of that factor in the incident.

General Factors
Dive Planning	0 1 2 3 4 5
Cave Familiarity	0 1 2 3 4 5
Experience	0 1 2 3 4 5
Visibility	0 1 2 3 4 5
Restriction: Stuck	0 1 2 3 4 5
Medical Problem	0 1 2 3 4 5
Buddy
General	0 1 2 3 4 5
Communications	0 1 2 3 4 5
Separation	0 1 2 3 4 5
Breathing Gas
Gas Supply	0 1 2 3 4 5
Hypoxia	0 1 2 3 4 5
Toxicity	0 1 2 3 4 5
Narcosis	0 1 2 3 4 5
Guide Line
Awareness	0 1 2 3 4 5
Missing/Damaged	0 1 2 3 4 5
Entanglement	0 1 2 3 4 5
Visual Jump	0 1 2 3 4 5
No Primary Run	0 1 2 3 4 5
Equipment Problems
Regulator	0 1 2 3 4 5
Valves	0 1 2 3 4 5
BC	0 1 2 3 4 5
Primary Light	0 1 2 3 4 5
Backup Lights	0 1 2 3 4 5
Fins	0 1 2 3 4 5
Mask	0 1 2 3 4 5
Exposure Suit	0 1 2 3 4 5
DPV	0 1 2 3 4 5

Additional Comments

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