Incident Report

Please feel out this report if anything occurs that interrupts the regular flow of activity in stable, riding areas, pasture etc. (All falls, loose horse, injury, hazard noted etc.)

Date, Time & Location:

Name of Reporting Person(s) [staff/visitor/student/rider/boarder]:

Issue or Concern/ Type of Incident [stuck/caught/fall/slip/trip/fire/explosion/tools or equipment/harmful substance/environmental]::



Weather Conditions:
Describe what happened:


Was an Ambulance called:(yes/no) How long before it arrived:
Was medical assistance provided before the ambulance arrived? (yes/no)
If “Yes”, describe what assistance was given and by whom:
Was the injured person a minor:(yes/no)
Age of the injured person:
Parent/Guardian Name(s):
Were any other people present who could describe what happened:________ (yes/no)
If “Yes”, provide the following for each person: Name Address Phone number


If the accident involved an equine provide the following information
Horse name & age:
Name of the horse’s owner(s), with Address & Contact Info:

Use of Horse at the time (i.e. School horse):

Describe physical problems of horse that may have been a contributing factor:

Indicate the horse’s experience in this activity:

Had the injured person ridden this horse before:(yes/no), how often

Did the injured person sign a Release Form:(yes/no) If “Yes”

Describe Property Damage, including vehicles (ownership and insurance details)





Detailed description (what was happening leading up to the incident? describe tools, equipment, weather, horses, people etc.)





Describe action taken at the time:





Horse [name/ownership/relevant bio deets]:




Description of human injuries:





Describe equine injuries:





Repairs Required/Details of Other Party Damage, Vehicles etc.)




Suggested Follow up as a result of incident/Personally intended Next steps:













Signatures:

Policy #: