Crash or Near Miss Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Bike Walk NE strives identify the locations of unreported crashes and safety issues within Nebraska communities. If you were involved in a crash or near miss while walking or biking and didn't report it please fill out the form below.

This is purely voluntary please do not share any details you are not comfortable sharing. Your information will not be shared. This is for data collection purposes only.

Place of Crash (Intersection, Trail, etc.) *

What City/Town was this in? *

Date of Crash (an approximate date works as well)

YYYY

Can you tell us what happened?

Was your bike damaged?

Yes

Clear selection

If yes, how much damage was done?

Less than $100

$100 - $250

$250 - $500

I had to replace my bike.

Other:

Clear selection

Were you hurt?

Yes

Clear selection

Were the police involved?

Yes

Clear selection

If the police weren't involved, can you tell us why?

The driver left the scene.

The driver asked for it not to be reported or offered something in return for not reporting.

I was too stunned, and didn't think of it.

I don't know the process for crash reporting.

I was uncomfortable calling law enforcement.

I didn't think there was enough damage/harm to report.

Other:

Clear selection

Is there any additional information we should know about?

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Bike Walk Nebraska.

Does this form look suspicious? Report

Forms