PBC Accident Report Form A form to complete when there has been an accident on a club ride. Name of person submitting this accident report*AddressCityStateZipEmail*Phone*Portland Bicycling Club Member?YesNoIf yes, member numberWas the injured person riding an e-bike?*YesNoIf yes, which kind?Pedal Assist? Requires pedalingThrottle Assist? Pedaling not required to move bikeDate of accident* Date Format: MM slash DD slash YYYY Time of accident* : HH MM AM PM Name(s) of injured person(s)Name of first injured person*AddressCityStateZipEmailPhoneGender Female Male Portland Bicycling Club Member?YesNoIf yes, member numberIf only one injured person, skip down to "Rider action at the time of accident"Name of second injured personAddressEmailPhoneGender Female Male Portland Bicycling Club Member?YesNoIf yes, member numberIf only two injured persons, skip down to "Rider action at the time of accident"Name of third injured personAddressCityStateZipEmailPhoneGender Female Male Portland Bicycling Club Member?YesNoIf yes, member numberRider action at the time of accident Turning right Turning left Being passed Passing Riding through an intersection Stopping Other, see description Type of road City street Rural road Multi-use trail Dirt trail Gravel trail Weather Sunny Cloudy Foggy Light rain Heavy rain Snowy Sleety Street condition Dry Wet Icy Snow covered Was a car involved?*YesNoIf yes, and information was collected, please supply here.Name of ride on which accident occurredName of ride leaderLocation of accident*Description of accident*CAPTCHA
