Cycling Incident Report
Assist Kiama BUG’s advocacy for a safer cycling environment – complete this report if you have had an accident or a 'near-miss'.
Sign in to Google to save your progress. Learn more
Name
Optional - Your name will not be provided to third parties.
Contact details
(Phone or email - Optional)
Date of Incident *
MM
/
DD
/
YYYY
Location of Incident / Issue *
Give as much detail of the location as possible as this will enable us to build up a profile of potentially hazardous areas and report to relevant government bodies.
Brief description of incident / Issue *
Give as much detail as possible regardless if you think the incident was your fault.   As an example; if you left the footpath and then went to ride back onto the same footpath but your wheel became caught beside the path and the grass, chances are these needs to be fixed. We are looking for common threads which help us again identify and report.
Did you require medical attention? *
Yes or No (no details are required)
Suggestions for improvement
Do you have any suggestions for how this situation could be avoided in the future? Signage? Infrastructure? etc. (Optional)
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Kiama BUG. Report Abuse
Google Forms