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

MonthDayYear
Person Making Report

First NameLast Name
Phone Number

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

YesNo
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?

YesNo
Provide information regarding the event (Tournament name, arena or outdoor, goal level, etc.)
Have the local authorities been notified?

YesNo
Were there any equine fatalities?

YesNo
Description of incident and your concerns:
Any Additional Information:
Should be Empty: