Location of Incident

Date of Incident

Hour of incident

Name of injured person

Age

Telephone #

Address of injured person

Nature of injury/details of how incident occurred (use back of form if more room needed)

Weather

◊ Clear ◊ Rain ◊ Snow ◊ Fog/Mist ◊ N/A

Surface Conditions

◊ Dry ◊ Wet ◊ Snow ◊ Ice ◊ Under repair ◊ Other (specify)

Light Conditions

◊ Daylight ◊ Dawn ◊ Dusk ◊ Darkness ◊ Artificial

Type of incident

◊ Fall ◊ Bike/Bike ◊ Car/Bike     ◊ Pedestrian/Bike ◊ Other (specify)

Medical Service Obtained

◊ No ◊ Yes If Yes, name hospital and address

Name of Attending Physician

First Aid administered

Names and addresses of witnesses 1.

Tel.

2.

Tel.

3.

Tel.

Name of Police Officer (if notified)

Badge # and Police Organization

Name of Ride Leader

Tel.

If incident involves a motor vehicle, please complete the following

Licence of Vehicle (Specify province or State) 1

Name and address of vehicle operator

Name and address of vehicle owner

If the motorist is not covered by ICBC, name address and policy information of vehicle insurer

Signed

Date