Accident / Incident report

Basic information

Date and time of incident

Name of person reporting

Contact telephone number

Your email address

A copy of your submission will be sent to this address

Approximate location

Name of manager/group leader/project leader

Cycling UK membership number (If applicable)

Injured person 1

Name of injured party

Cycling UK membership number (If applicable)

Contact phone number

House name or number

Street

City/Town

Postal Code

Role on ride

Was the rider a guest, volunteer, leader, etc?

Parents/Guardians/Next of kin contacted?

Name of person contacted

Contact phone number

Relationship to injured party

Time of call

Were any other people injured?

Yes

Injured person 2

Name of second injured party

Cycling UK membership number (If applicable)

Contact phone number

House name or number

Street

City/Town

Postal Code

Role on ride

Was the rider a guest, volunteer, leader, etc?

Parents/Guardians/Next of kin contacted?

Name of person contacted

Contact phone number

Relationship to injured party

Time of call

Relationship to injured party

Were any other people injured?

Yes

Injured person 3

Name of third injured party

Cycling UK membership number (If applicable)

Contact phone number

House name or number

Street

City/Town

Postal Code

Role on ride

Was the rider a guest, volunteer, leader, etc?

Parents/Guardians/Next of kin contacted?

Name of person contacted

Contact phone number

Time of call

Accident details

Did the accident/incident happen during a group ride/event?

Cycling UK Group/Club Name/Project name (If applicable)

Was this an accident or near miss?

General description of incident

Is there any negligence and if so who is responsible?

If the incident involves a vehicle

Name of driver

Vehicle registration

Make/Model

Colour

Incident reporting details

Hospital details

Police details

Incident number

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Accident / Incident report