USPA Equine Welfare Incident Report Form

USPA Equine Welfare Incident Report Form
Submission of this form is completely confidential. If you would like to be contacted after submission for additional questioning, you may provide your contact information.
Date and Time of Report

Month Day Year
Person Making Report

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
Is there anyone else we should contact about the incident? (i.e. veterinarians, other members, etc.)

Yes No
If yes, please provide their names and contact info.

Horses Involved:

	Name of Horse	Body Condition Score	Description (Age, Sex, Color, Markings, ect.)
Horse 1
Horse 2
Horse 3
Horse 4
Horse 5
Horse 6

Was this incident at a USPA Event, Club Event or USPA Supported Activity?

Yes No
Provide information regarding the event (Tournament name, arena or outdoor, goal level, etc.)
Have the local authorities been notified?

Yes No
Were there any equine fatalities?

Yes No
Description of incident and your concerns:
Any Additional Information:
Should be Empty: