Wisconsin MSP - MSF Incident Rep (01/23)

INCIDENT REPORTING

Filing the Report

RiderCoach(es) must file the attached MSF Incident Report when there is any injury, potential injury or property damage, even if it appears minor, to any participant, vehicle or pedestrian involved in an incident. If more than one person or vehicle was involved in the incident, a separate MSF Incident Report must be filed for each. The RiderCoach(es) coaching at the time of the incident must complete the MSF Incident Report as soon after the incident as is possible. Each section of the report must be completed. Include complete range address information and an accurate depiction of the range layout at the time of the incident. Be sure to include all information on the student(s) involved, including contact information. No section can be blank. If information is not available, please note on the form by using “N/A” (not applicable) in the appropriate space. Witness information must include name, address, phone number, and email address. Other RiderCoaches or students may be included as witnesses. Include all information available in the summary and ensure statements are recorded accurately.

Send the photos (if available) and the MSF Incident Report directly to the MSF WITHIN 48 HOURS OF THE INCIDENT. Preferred method of notification is to scan and email to lbrehm@msf-usa.org. Be sure the report is completed in full; no blank spaces. If a state-required police report has been completed, please forward a copy as soon as it is available.

The incident should NOT be discussed with any individual (e.g., an attorney, reporter, magazine writer, student, friend or neighbor) other than authorized program personnel, insurance provider or MSF legal counsel.

Rev 09/2019

Training site name (Range)

RERP number:

Sponsor name:

Sponsor address:

Street, City, State, Zip

Range number (Site ID):

Range street address:

Length:

Width:

Type of range:

StandardAlternate (Posted in RETSORG)Modified (Custom)

Date of incident:

Date

Time

Hour Minutes

AM/PM Option

RiderCoach #1:

Full Name

RiderCoach #1 MSF ID#:

RiderCoach Number

RiderCoach #2:

RiderCoach #2 MSF ID#:

Additional RC or other site personnel:

ID#:

RiderCoach number or Driver's License number

Number of Riders:

Number of RiderCoaches:

Number of range aides or other personnel:

Name

First NameLast Name

Gender:

MaleFemale

Date of birth:

Date

Address

Street Address

Street Address Line 2

CityState/Province

Zip CodeCountry

Telephone number:

Format: (000) 000-0000.

Email:

example@example.com

DL#:

License State or Country:

Person potentially injured or involved (check one):

StudentRiderCoachOther

RiderCoach estimate of the rider's experience level:

Never riddenBeginner with some experienceExperiencedUnknown

Did involved person show signs of intoxication?

YesNo

If yes, describe

RiderCoach summary (include details such as RC and student location, distances, path of travel and circumstances):

Student's summary:

Student's signature:

Date:

Date

Was this the person's first incident during the training session today?

YesNo

If no, how many previous?

Incident occurred during:

Exercise name (BRCu updated):

Exercise name (BRC2 updated):

Exercise name (ARC):

Exercise name (3WBRC):

Exercise name (IME):

Exercise name (BBBRC):

Exercise name (UBBRC):

Exercise name (RRBRC):

Exercise name (CRC):

Other (include Course Name, Ex. Name & #)

The PRIMARY factor leading to the incident involved

Did the participant travel outside the range and runoff area during the incident?

YesNo

If yes, explain:

Approximate speed rider was traveling:

MPH

Object hit other than ground (e.g., fence, pole, curb, car, etc.)?

YesNo

If yes, describe object

Force of impact at time of the incident? (check one)

LowMediumHighN/A

Was there a helmet impact?

YesNo

Helmet Type:

Full-face helmets3/4 helmet1/2 helmet

Rider wearing proper protective gear (as defined in MSF documents) at the time of the incident?

YesNo

If No, explain:

Did the rider’s protective gear come off/shift?

YesNo

If Yes, describe:

Was the involved person injured?

InjuredPossible InjuryNo Injury

Nature of injury or possible injury (check all that apply):

RiderCoach description of injury

Treatment of injury (choose only one):

NoneSeeking own aidBasic First aid, administered by:Other

Basic First aid, administered by:

Injured person transported for medical assistance?

YesNo

If yes, specify

Ambulance/Paramedic:Other

Ambulance/Paramedic:

Company name and address

Other, specify:

Company name and address

Did involved person refuse any treatment?

YesNo

Did a representative of the RERP or training site follow up with the involved person?

YesNo

If yes, specify results:

Hospitalized:Other, specify:

If Hospitalized:

Treating physician and hospital

If Other, specify:

Did rider continue?

YesNo

If no, self-selected out?

YesNo

Describe relevant weather conditions:

Using the range diagram, indicate the location and the RC position at the time of the incident. If the rider left the perimeter, please indicate the distance and path traveled from the perimeter. Include obstacles. Include additional diagrams/text as needed below.

Additional explanation of range diagram, if needed:

Name:

Email address:

example@example.com

Telephone number:

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Name:

Email address:

example@example.com

Telephone number:

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Did police/law enforcement investigate:

YesNo

If yes, name of agency:

Was there damage to the motorcycle?

YesNo

If yes:

Slight damageModerate damageExtensive damage

Describe in detail the damage *(Note at the bottom of form):

Optional photo of bike/property damage #1 (click/tap below to take photo or upload photo from your device)

Did the motorcycle continue to be used?

YesNo

Motorcycle owner:

Brand:

Model:

CC Size:

VIN#:

Optional: Take Photo of VIN#:

Preparer’s signature:

Preparer’s name (please print):

Date Form Submitted:

Date

Preparer's Telephone number:

Format: (000) 000-0000.

Preparer's email address - if you would like a PDF of the completed report sent to you, enter your email address here:

*Pictures of the motorcycle are required for damages for those sites participating in the Training Motorcycle Loss/Physical Damage Plan, or as required by an authorized program. Send the photos (if available) and the MSF Incident Report directly to the MSF WITHIN 48 HOURS OF THE INCIDENT. Scan and email to lbrehm@msf-usa.org.

MSF Incident Report

I. BACKGROUND

II. PERSON INVOLVED

III. INCIDENT DETAILS

IV. INCIDENT OUTCOMES

V. WITNESS INFORMATION

1st Witness

2nd Witness

VI. MOTORCYCLE