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 the form and notify the USPC Executive Director.

Person Completing the Report

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Person Involved in Incident Information

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Incident Information

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Protective Equipment Used

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Contributing Factors

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CLICK Submit only ONCE. It may take a moment for the form to submit.