Cycling BC Accident Report Form

Incident Level

Injured: Full Name*

Injured: Phone Number*

Injured Email Address*

Injured: Cycling BC Membership #

Date of Accident:*

Time of Accident:*

HH :

MM

Event Type:*

Event / Activity Name:*

Injury: Summary*

Injury: Full Description

Describe the extent of the injury and the situation leading up to the accident

First Aid Attendant Name

First Aid Attendant Emal

Witness: Full Name*

Witness: Phone Number

Event Organizer: Full Name

Event Organizer: Phone Number

Was First Aid administered at the scene?

Was an ambulance called to the scene?

What hospital was the Injured Person taken to:

Please list any other relevant information:

Photo / Document Upload

Optional - 24mb max

Digital Signature*

This form must be completed as much as possible, and be submitted to Cycling BC within 7 days of the injury. If available, please attach any reports from the first responder. This document and its contents are privileged; they were prepared in anticipation of litigation. For additional correspondence, email [email protected]

Yes - I have completed this form to the best of my ability

Email of Person Submitting Report*

Comments

This field is for validation purposes and should be left unchanged.