PBC Accident Report Form -Portland Bicycling Club

Name of person submitting this accident report*

Address

City

State

Zip

Email*

Phone*

Portland Bicycling Club Member?

Yes
No

If yes, member number

Was the injured person riding an e-bike?*

Yes
No

If yes, which kind?

Pedal Assist? Requires pedaling
Throttle Assist? Pedaling not required to move bike

Date of accident*

Time of accident*

:

Name(s) of injured person(s)

Name of first injured person*

Address

City

State

Zip

Email

Phone

Gender

Female
Male

Portland Bicycling Club Member?

Yes
No

If yes, member number

If only one injured person, skip down to "Rider action at the time of accident"

Name of second injured person

Address

Email

Phone

Gender

Female
Male

Portland Bicycling Club Member?

Yes
No

If yes, member number

If only two injured persons, skip down to "Rider action at the time of accident"

Name of third injured person

Address

City

State

Zip

Email

Phone

Gender

Female
Male

Portland Bicycling Club Member?

Yes
No

If yes, member number

Rider 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?*

Yes
No

If yes, and information was collected, please supply here.

Name of ride on which accident occurred

Name of ride leader

Location of accident*

Description of accident*