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Accident Incident and Near Miss Report Form. Form completed by Expedition Date Time Location GPS Reference Description of site Weather conditions Name s of person s involved Address es What injury was diagnosed by whom What treatment was given at the site and by whom What medication was given By whom Overall assessment of casualties condition If unconscious what level Action taken including description of how the casualty was evacuated state of casualty during evacuation and where evacuated to if applicable Full details of accident / incident and action taken were any photographs were taken and by whom Include a diagram if appropriate Any other relevant information relating to this accident / incident Names addresses and signatures of witnesses with any relevant notes Name address telephone number of hospital/clinic Names of Trip Leaders Signatures I / We confirm that this the details on this form have been correctly recorded Name s signature s of the person s in charge of the group Supplementary information Was the incident preventable To prevent future occurrence what changes should be made or what do you recommend Have any other changes been made in the light of this incident Has GWM Office been informed Name Signature date Additional Notes Insurance Company Communications Is it important that as soon as possible the leader or client if possible must contact the insurance company if a claim is to be made. If it is not possible for the leader to do this then let the local agent know and they can do it for you. Name of insurance company and policy number Date and time of first communication Name of person who made the call Contact at insurance company case reference no. Log of communication with insurance company Go Wilderness Mongolia Co Ltd. Emergency Contact Details Chris Cartwright Mobile GWM Satellite phone Sarol mobile GWM office GWM email GWM Fax UK 99 158 130 98 051 234 English 99 855 116 English / Mongolian 11 379097 info gowildernessmongolia*com 0871 900 40 60 SOS emergency line SOS after hours SOS mobile SOS office SOS fax SOS email 9191 3122 11 464 325 99 110 335 99 096 175 11 454 537 admin sosmedicamongolia*mn British Embassy 11 458 133 11 458 036 britemb mongol*net Fax Bodi Insurance Chinese / English 70 110 280 10 6462 9100. If it is not possible for the leader to do this then let the local agent know and they can do it for you. Name of insurance company and policy number Date and time of first communication Name of person who made the call Contact at insurance company case reference no. Name of insurance company and policy number Date and time of first communication Name of person who made the call Contact at insurance company case reference no. Log of communication with insurance company Go Wilderness Mongolia Co Ltd. Emergency Contact Details Chris Cartwright Mobile GWM Satellite phone Sarol mobile GWM office GWM email GWM Fax UK 99 158 130 98 051 234 English 99 855 116 English / Mongolian 11 379097 info gowildernessmongolia*com 0871 900 40 60 SOS emergency line SOS after hours SOS mobile SOS office SOS fax SOS email 9191 3122 11 464 325 99 110 335 99 096 175 11 454 537 admin sosmedicamongolia*mn British Embassy 11 458 133 11 458 036 britemb mongol*net Fax Bodi Insurance Chinese / English 70 110 280 10 6462 9100.

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