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* 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* MM slash DD slash YYYY Time of accident* : Hours Minutes AM PM Name(s) of injured person(s)Name of first injured person* Address City State Zip Email PhoneGender 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 PhoneGender 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 PhoneGender 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*CAPTCHAUntitled Δ
