Incident Report - United States Pony Clubs

Incident Report

This form is to be completed by the DC/CA/RS, SO (Safety Officer) or DP (Designated Person) 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 this form and notify the USPC Executive Director.

Person Completing the Report

First Name

Last Name

Club/Center

Position

Region

Person Involved In the Incident

First Name

Last Name

Age

Gender

Phone

If this report is on a minor, please provide the Parent/Guardian's name

Address

City

State

Zip

Incident involved - check all that apply

Pony Club Member - Mounted

Pony Club Member - Unmounted

Parent

Volunteer

Official

Spectator

Other

Incident Information

The person involved...

Date of Incident

Address

City

State

Zip

Where did the incident occur?

Type of Pony Club activity

Did the incident occur durring a specific activity?

Did the incident involve jumping?

Please describe what happened in as much detail as you can provide

Please describe the nature of the injuries

Did the incident involve the head?

Were there signs of a concussion?

Protective Equipment Used

Was a helmet worn?

Was a protective vest worn?

Were safety stirrups being used?

Please list any other protective equipment that was used.

Contributing Factors

Was weather a factor in the incident?

Was the footing a factor in the incident?

Were there and distractions that may have contributed to the incident?

Any other information to share about the incident?