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)
4. Incident Location (street name/ route number/ intersection/ path name) *
5. RBC map # or name (if applicable)
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, sun glare, foggy, rain/sleet/snow, windy).
11. 911 - if called, what agency responded to the call?
12. Injuries - describe any injuries in detail.
13. Medical Treatment - state where, when, from whom and the nature of the treatment received.
14. Incident Description - include speed, direction of travel of cyclist (and others if involved), lane position, signage/signals and other important information. *
15. Contact Information - enter the name, email, and phone number of person completing the report.
16. Suggestions - state any suggestions you may have that would prevent this type of incident in the future.
17. Comments - enter any additional comments or observations here.
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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