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

Person Involved In the Incident

Incident involved - check all that apply

Incident Information

Protective Equipment Used

Contributing Factors