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TCC Incident/Accident Report
Thank you for fillling out this incident/accident report. Please provide as much of the requested information as possible. If more than one person was injured, please fill out a reponse for each one, by selecting "SUBMIT ANOTHER RESPONSE" at the end of the form to get to a new response form. For additional subjects, you may skip the description of the incident/accident and just report on the subsequent person(s) who were involved. If there is additional infomation you need to convey, please feel free to email the Club President or Treasurer. Also, please phone / email the Club President or Club Treasurer to let them know you have filed an online report.
Person Making this Report:
Your answer
Date of Report
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Subject's Name:
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Subject's Street:
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Subject's Town:
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Subject's Contact Phone:
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Subject's Date of Birth
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Does the subject identify as male or female?
Date of Incident:
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Time of the incident:
Time
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Location of the incident:
Your answer
Briefly describe the weather (temperature, wind, visibility, any precipitation?):
Your answer
Type of Incident
Type of TCC activity or event where incident occured?
Did the subject have to abandon the TCC activity or event?
Did the subject require outside assistance (emergency medical, police)?
Did the subject go to a medical facility?
If so, what medical facility (hospital, walk-in clinic, famly doctor)?
Your answer
Was the subject able return and continue the TCC activity?
Was the subject's emergency contact or family contacted?
Name of the emergency contact?
Your answer
Briefly, describe the location (head, torso, right leg, lower back, left side of face, etc.) of any injuries and the nature (deep cut, abraision, swelling) of any injuries:
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If bodily fluids were present were universal precautions followed?
NARRATIVE: In the following space please provide a brief, factual account of this incident. Describe the setting including road name, number of riders, and any other factors that may have been involved (e.g., vehicles, wet road, pothole, curb, etc.).Describe any and all symptoms of injury and/or illness that subject exhibited Describeyour response to the accident and/or your treatment of the patient. Please forward to the TCC President or Treasurer any patient care forms, Police or EMS Report forms, and/or photos.
Your answer
Names of witnesses or club members who assisted subject during/after the incident. Please ask witnesses to foward individual narrative statements to the TCC President or Treasurer.
Your answer
How's the bike?
Your answer
Is there anything else you need to report about the incident?
Your answer
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