PBC Accident Report Form A form to complete when there has been an accident on a club ride. Name of person submitting this accident reportAddressEmailPhonePortland Bicycling Club Member?YesNoIf yes, member numberDate of accident Time of accident : HH MM AM PM Name(s) of injured person(s)Name of first injured personAddressEmailPhoneGender 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 personAddressEmailPhoneGender 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 accidentDescription of accident
