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, object 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 as possible after the incident.

    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 regarding the student(s) involved, including contact information. No section should be blank. If information is not available, please note on the form by using “N/A” (not applicable) in the appropriate space(s).

    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 photos (if available) and the MSF Incident Report directly to the MSF WITHIN 48 HOURS OF THE INCIDENT. Scan into a PDF file 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 02/2024

  • MSF Incident Report

    Revision Date: 09/19

  • Important – Don’t lose your work!

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  • I. BACKGROUND

  • Type of range:
  • Date of incident:
     / /

  • II. PERSON INVOLVED

    (Use a separate form for each person involved.)
  • Gender:
  • Date of birth:
     / /
  • Format: (000) 000-0000.
  • Person potentially injured or involved (check one):
  • RiderCoach estimate of the rider's experience level:
  • Did involved person show signs of intoxication?

  • III. INCIDENT DETAILS

  • Date:
     / /
  • Was this the person's first incident during the training session today?
  • Incident occurred during:
  • The PRIMARY factor leading to the incident involved
  • Did the participant travel outside the range and runoff area during the incident?
  • Object hit other than ground (e.g., fence, pole, curb, car, etc.)?
  • Force of impact at time of the incident? (check one)
  • Was there a helmet impact?
  • Helmet Type:
  • Rider wearing proper protective gear (as defined in MSF documents) at the time of the incident?
  • Did the rider’s protective gear come off/shift?

  • IV. INCIDENT OUTCOMES

  • Was the involved person injured?
  • Nature of injury or possible injury (check all that apply):
  • Treatment of injury (choose only one):
  • Injured person transported for medical assistance?
  • If yes, specify
  • Did involved person refuse any treatment?
  • Did a representative of the RERP or training site follow up with the involved person?
  • If yes, specify results:
  • Did rider continue?
  • If no, self-selected out?

  • V. WITNESS INFORMATION

  • 1st Witness

  • Format: (000) 000-0000.

  • 2nd Witness

  • Format: (000) 000-0000.
  • Did police/law enforcement investigate:

  • VI. MOTORCYCLE

  • Was there damage to the motorcycle?
  • If yes:
  • Did the motorcycle continue to be used?
  • Date Form Submitted:
     / /
  • Format: (000) 000-0000.

  • *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.

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