RUSA Incident Report

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Email *

Event Name / Permanent Route # *

Event / Permanent Distance (indicate miles or kms) *

Event / Permanent Calendared Date *

YYYY

Ride Type *

Main Event

Worker's Ride

Permanent

RUSA Region (N/A if Permanent) *

Injured Person Name *

Injured Person RUSA Number *

Injured Person Email Address *

Injured Person Mailing Address *

Injured Person Telephone Number *

Date of Incident *

YYYY

Time of Incident *

Time

Distance at time of incident (indicate miles or kms) *

Location of incident *

Incident description *

Injury description *

Disposition (refused care, medical attention, ambulance etc) *

RBA Name, Region and contact info ("N/A" if Permanent) *

Witness(es) contact info

Confirm that you are sending a copy of the signed waiver to incident@rusa.org *

Submit

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