* 1. What department sponsored this trip?

* 2. What is the title of your trip?

* 3. What was the location of this trip?

* 4. Who were the leaders for this trip? (First and Last name, please)

* 5. What is the primary email address for the trip leader(s)?

* 6. What was the start date/time of your trip?

* 7. What was the end date/time of your trip?

* 9. Total Driving Mileage (ex. 3 vehicles on the trip, 50,49, and 50 miles driven. Total mileage = 149)

* 10. Detailed Feedback: Things that worked well that you would do again (Pros)

* 11. Things that you wish you had done, things that you wish you hadn't done (Grows)

* 12. A NEAR MISS is a “close call” – a potentially dangerous situation where physical or emotional safety was compromised without significant injury (or any injury). It is an unplanned or unforeseen event that as leaders we hope to avoid repeating in the future. Significant learning occurs only by documenting these events.

Examples include but are not limited to the following:
1 Any emotional or behavioral incidents affecting personal and/or group safety.
2 Any close or aggressive encounter with a person or an animal.
3 Any situation where someone becomes lost or disoriented, either while traveling or around camp.
4 Any human error operating equipment. Examples: losing traction while driving, spilled hot water, improper belay technique or tie in, etc.
5 Any event concerning the malfunctioning of equipment (personal or group). Examples: vehicle break down, stove flare ups/explosions, climbing/rafting gear wear/tear, missing items to specific first aid/repair kits, etc.
6 Any rock fall, falling object, or rolling rock event that would result in significant injury, in the event of a hit, and in which the rock or object lands within 5 meters of a person.
7 Any unplanned or unanticipated swim or wrap/flip/pin while river crossing, rafting, or kayaking.
8 Any avalanche event that occurs within 5 meters of a person.

Do you believe that you had a Near Miss on your trip?