SLOBC Incident Reports 24

SLOBC Incident Report

Use for Weekly, Monthly and Annual Ride Events but NOT Century rides. Create a separate report for each rider involved.
SLOBC Ride or Event Name*
Vacillators, Pie Ride
Incident Date*

MonthDayYear
Incident Time*

Hour Minutes

AM/PM Option
Incident Classification*

Minor: Bumps, Bruises, Road RashMajor: Abandoned Ride or Police or EMS Dispatched
Road Type

PavedGravel/DirtOther
Road Condition

DryWetOther
Incident Location

HighwayRural RoadCity StreetBike LaneBike PathParking LotOther
Incident Activity

Turning RightTurning LeftGoing StraightBeing PassedPassingIntersectionStationaryOther
Incident Cause

Road PotholeRoad Debris/SandPavement Crack/SeamPavement Bump/EdgeStruck - ObjectCollision - Parked CarCollision - Moving CarCollision - AnimalCollision - Participant/ParticipantCollision - Non-ParticipantOverexertionEquipment FailureOther
Road Name + Address, Intersection, GPS Coordinates
Description of How Incident Occurred
Vehicle Involved*

NoYes (adds questions)
Driver Name

First NameLast Name
Driver License Number & State
Vehicle License Number & State
Officer Present*

NoYes (adds questions)
Officer Affiliation
Officer Name

First NameLast Name
Officer Report Number
Rider Involved in Incident*

First NameLast Name
Phone Number
Please enter a valid phone number.
Affiliation

SLOBC MemberNon-Member
Helmet

YesNo
Bike

Single BikeSingle E-BikeTandem BikeTandem E-BikeTrikeE-Trike
Injury*

NoYes (adds questions)
Body Part Injured

FootAnkleKneeLegHipBackNeckHeadFaceShoulderArmElbowWristHandOther
Description of Injuries
Disposition*

Report SubmittedPolice ReportMedical AttentionTransport by AmbulanceHospital Self TransportEmergency Contact CalledRefused CareOther
Witness

First NameLast Name
Witness Phone Number
Please enter a valid phone number.
Member Submitting Report*

First NameLast Name
Member Email*
Submit the Report and a copy will be emailed to you and the SLOBC Board.

Save a Draft and you will be emailed a link to complete the report.
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