Incident Report Form - US Pony Clubs

Incident Report Form

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This form is to be completed by the DC/CA/GL/RS, who should note the circumstances of any incident that occurs at a Pony Club activity.

In the case of a very serious incident, please complete the form and notify the USPC Chief Executive Officer.

If you prefer, you may complete a hard copy of the Incident Report Form and mail to the National Office.

Injured Person Information
First Name *		Last Name *
Center/Club/ Group *		Region *
Information regarding the person injured
Full Name *		D.O.B. *
Gender *		Current Ceritification Level *
Club/ Center/ Group *		Region *
Parent/ Guardian Name *		Phone *
Address		Email Address
City		State
Incident Information
Information and description regarding the incident
Date of Incident *		Incident Involved (check all the apply) *	PC Member/ Rider Spectator Parent Volunteer Official PC Member Unmounted Other
Location of the Incident *
Address
Incident involved the head? *	Yes No	Were there signs of a concussion? *	Yes No
Was the individual pulled from participation? *	Yes No N/A	Did the invidual return to participation after a break? *	Yes No N/A
Member/Parent was given a Return to Play Form to complete? *	Yes No	Where did incident occur? *	Stable Show Ring Dressage Ring Warm Up area Parking area
Other (Specify)
Type of Pony Club Activity *	Mounted Meeting Unmounted Meeting Rally Camp
Other (describe)
Fundraiser (Describe)
Discipline Involved	Dressage Eventing Games Polocrosse Quiz Show Jumping Tetrathlon
If incident involved jumping	Show Jumping Cross Country
What type of fence?		Approx. Height
Describe What Happened *
Describe nature of Injuries *
The person involved... *	Required no treatment, continued with activity Require no treatment, but declined to continue with activity Required Treatment, returned to activity Required treatment, was unable to continue with activity Serious injury, was transported to hospital
Protective Equipment Used

ASTM/SEI Helment *	Yes, an ASTM/SEI Helmet Yes, another Helmet Type No Helmet worn
If yes, please provide make, model & year
Was a protective vest worn? *	Yes, an Impact Vest Yes, an Inflatable Vest No Vest worn
If yes, please provide make, model and year
Safety Stirrups *	Yes No	If yes, what type of stirrups
Other Protective Equipment Used
Contributing Factors

Weather (explain)
Footing (explain)
Distractions (give details)
Other

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