Bicycle Injury Accident Report
This report is a joint project of the The Villages Bicycle Club and the Sumter Landing Bicycle Club designed to improve bicycling safety in The Villages and surrounding areas.

Report those accidents requiring professional medical treatment for the rider that occurred in Sumter, Lake or Marian counties, Florida. The Sumter Landing Bicycle club is attempting to learn more about injury accidents and how we might prevent them in the future. The use of this form is not restricted to Sumter Landing Bicycle Club or The Villages Bicycle Club members. This form is not an insurance claim reporting tool.
Date of accident *
mm/dd/yr
Your answer
Time of accident *
Required
Where did the accident occur? *
check all that apply
Required
Road Conditions *
check all that apply
Required
Location of accident *
street(s), village, county
Your answer
Did the accident involve a Village's gate? *
Medical attention required *
check all that apply
Required
Did the accident occur in a traffic circle?
Was a car, truck or motorcycle involved *
Required
Did the accident occur during a group ride? *
Required
Was another bicycle involved? *
Required
Was a citation issued as a result of your accident? *
Please check the appropriate box
Required
Did the accident occur during an organized or club ride? *
Required
Gender of Rider *
Required
Age or Rider
Rider Experience *
Estimate the miles cycled in the 12 months prior to your accident
Required
Bicycle *
Required
Accident description *
include how the accident could have been prevented
Your answer
Name of contact for additional info
Optional
Your answer
Email address for additional info
Optional
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms