This report is designed to obtain information that may help the club to determine future areas of safety education. You may review and revise any of your responses prior to submitting this form.
1. Date of Incident *
2. Time of Incident *
3. Individual Involved (indicate if RBC member)
Your answer
4. Incident Location (street name/ route number/ intersection/ path name) *
Your answer
5. RBC map # or name (if applicable)
Your answer
6. Type of Bicycle Involved
7. Type of Vehicle (if applicable)
8. Cyclist Activity (check all that apply)
9. Road Surface and Road Conditions (check all that apply)
Loose gravel on paved road
Potholes / construction
Chip sealed
Paved road
Unpaved road
10. Weather Conditions - (e.g., clear, foggy, rain/sleet/snow, windy).
Your answer
11. 911 - if called, what agency responded to the call?
Your answer
12. Injuries - describe any injuries in detail.
Your answer
13. Medical Treatment - state where, when, from whom and the nature of the treatment received.
Your answer
14. Incident Description - include speed, direction of travel of cyclist (and others if involved), lane position, signage/signals and other important information. *
Your answer
15. Contact Information - enter the name, email, and phone number of person completing the report.
Your answer
16. Suggestions - state any suggestions you may have that would prevent this type of incident in the future.
Your answer
17. Comments - enter any additional comments or observations here.
Your answer
18. Print - a printed copy of your responses must be done before submitting by selecting print from your browser. Have you printed your file before selecting Submit?
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