USPA Equine Injury/Fatality Reporting Form

USPA Equine Injury/Fatality Reporting Form
Submission of this form is completely confidential and will only be used as a report of the incident. You may be contacted after submission for additional questioning.
Date and Time of Report

MonthDayYearHourMinutesAM/PM Option
Name of Person Reporting Incident

First NameLast Name
Phone Number of Person Reporting Incident

Area CodePhone Number

Date and Time of Incident

MonthDayYearHourMinutesAM/PM Option
Location of Incident (Club Name)
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Horse(s)
Age of Horse(s)
Body Condition Score
Fitness Level of Horse
List any medications the horse is currently on
Was the horse shod or barefoot

Shod on frontShod on all fourBarefoot
Suspected Injury/Cause of Death

Name of Owner
Name of Player (If different than owner)
Outdoor Handicap of Player
Arena Handicap of Player
Women's Outdoor Handicap of Player
Women's Arena Handicap of Player
Horse's Veterinarian
Club Veterinarian
Host Tournament Committee

If during training, intensity of training

LowMediumHigh

If during practice, please explain incident

If before game, please explain incident

If after game, please explain incident

Should be Empty: