Bicycling Incident Report form

This form was created by SafeBicyclingData.org to provide a way of reporting an incident that occurred while riding your bicycle on roads in any state in the U. S. The incident may be a near miss or close call, where you were not injured, or a crash resulting from any interaction with a motor vehicle or bicycling infrastructure along a road. Relatively minor incidents resulting in crashes are seldom reported but are important to know about.

These reports will be used to build a database to evaluate cycling safety on the roads in your state or locality. These results and issues will then be shared with local cycling clubs and advocacy groups and appropriate local, county, and state agencies to assist them in addressing and resolving cycling safety issues, thereby creating safer cycling community for all residents and visitors.

SafeBicyclingData.org is an independent organization, not affiliated with any government agency and does not received financial or other considerations to provide this form for incident reporting.

The form will take about 3 minutes to fill out the 37 questions.

Created February 23, 2016 by Robert S. Fritz, Tucson, AZ
Do not copy without written permission

    Information About You

    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question

    Information about this incident

    :
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question

    Location of Incident

    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question

    Incident Detail

    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question

    Reaction to Incident

    This is a required question
    This is a required question
    This is a required question

    Personal Information

    This is a required question
    This is a required question