Accident Report Form for Painted Bar Stables
Please only use facts that you WITNESSED of the accident. Do not report secondary information or evaluate horses as longstanding problems. Only use witnessed facts that occurred during the incident.

Please keep information private. Only barn staff will be able to view the results. All information reported is confidential for both the horse and the rider.

Improper or absuive use of this form will result in reprimand.
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Name of Person Involved *
Person Involved was a: *
Address of Person Involved
Contact Information of Person Involved
Put the name of the person who booked the ride if unknown
Date of Incident *
Time of Incident *
Was the person injured? *
If injured, please explain the injuries sustained during the incident.
Explain even minor injuries.
Was the individual examined and/or treated by a physician?
Clear selection
If they were treated or examined by a physician, who and where?
Incident Information
Where did the incident occur? *
Where did the incident occur? *
Riding style when incident occurred *
The incident occurred when the person was *
Person's Estimated Riding Level *
1 = Beginner/Novice    5 = Average Skills/Experienced      10 = Very Experienced/Skilled
First Time Rider
Advanced and Skilled Expert
Had the person demonstrated basic horse control? *
Was the person wearing a properly fitted ASTM/SEI certified helmet? *
What was the weather at the time of the incident? *
Choose all that apply.
Required
What was the temperature? *
In Fahrenheit
Was the person a minor? *
Age if under 18
Number of People in the Group *
Number of Instructors supervising the group *
Describe the Important Details of What Happened *
Name and Contact Information of Witnesses
Equipment Involved
Was there a tack malfunction? *
Required
Was the malfunction a result of:
What happened with the tack to cause the malfunction
Has the equipment been repaired and is it ready for use again?
If the helmet sustained impact, has it been removed from the inventory?
Horse Involved in Incident
Sex of Horse involved in Incident *
Which was the primary horse involved in the incident? *
Select all horses that were secondary players in the incident.
Was the horse owned by Painted Bar Stables
Clear selection
How long has this horse been used at Painted Bar Stables *
Was this horse in regular use prior to the incident? *
Click answer and Other if elaboration is needed
Required
What level of rider is this horse usually used for? *
Choose no more than 3 Options
Required
Instructor Information
Barn Staff Responsible at Time of Incident *
Choose multiple if necessary.
Required
Age of Instructors
Name of Person Filling Out This Form *
Submit
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