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 the form and notify the USPC Executive Director.

Person Completing the Report

First Name *

First Name is required.

Last Name *

Last Name is required.

Club/Center *

Club/Center is required.

Region *

Region is required.

Position: *

Postion is required.

Person Involved in Incident Information

First Name *

First Name is required.

Last Name *

Last Name is required.

Age *

Age is required.

Gender *

Gender is required.

Incident involved - check all that apply *

Pony Club Member - Mounted

Pony Club Member - Unmounted

Parent

Volunteer

Official

Spectator

Other

Address

City

State

Zip

Phone

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

Incident Information

The person involved... *

Date of Incident *

Date is required.

Location of Incident *

Answer is required.

Address *

Answer is required.

City *

Answer is required.

State *

Answer is required.

Zip *

Answer is required.

Where did the Incident occur? *

Answer is required.

Type of Pony Club activity *

Did the incident occur during a specific activity? *

Answer is required.

Did the incident involve jumping? *

Answer is required.

Describe what happened in as much detail as you can provide *

Answer is required.

Describe the nature of the injuries *

Answer is required.

Did the incident involve the head? *

Answer is required.

Were there signs of a concussion? *

Answer is required.

Protective Equipment Used

Was a helmet worn? *

Answer is required.

Was a protective vest worn? *

Answer is required.

Were safety stirrups being used? *

Answer is required.

Please list any other protective equipment that was used. *

Contributing Factors

Was weather a factor in the incident? *

Answer is required.

Was the footing a factor in the incident? *

Answer is required.

Were there any distractions that may have contributed to the incident? *

Answer is required.

Any other information to share about the incident?

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