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PAGEMILL PASTURES 3450 Deer Creek Rd., Palo Alto, CA 94306 |
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INCIDENT REPORT FORM Name of person involved:_____________________________________________________________ Address/Phone # of person involved:___________________________________________________ Date of incident:________________Time___________Was the person injured?_________________ Was the individual examined and/or treated by a physician? If yes, who and where? ___________________________________________________________________________________ Injuries sustained during the incident:___________________________________________________ ___________________________________________________________________________________ INCIDENT INFORMATION Person’s riding style when incident occurred: English______Western______Bareback_______Trail ride________Other________________ Person’s estimated riding level: Beginner/novice_______Experienced/average skills_______Very experienced/skilled______ Had the person demonstrated basic horse control?_______________ What was the person wearing at the time the incident occurred? A. Shoes with a hard sole and definite heel: YES______NO_______ B. Was the person wearing a properly fitted helmet designed for equestrian use YES_________NO___________ At the time of the incident the weather was:________________ Was the person a MINOR?_______Age if under 18:________ Was Parent or Guardian notified?____________________ The incident occurred: In the ring________ On the trail_________ Other_____________ The incident occurred when the person was: Mounted________ Unmounted__________ Number of people in the group_______Number of Instructors supervising the group_________ Is/was/were the Instructor(s) CHA certified?_________ Instructor’s age(s):__________ Type of horse involved in incident: Mare____________ Gelding________ Stallion________ Age of horse involved: ____________ Owned or leased?_____________ How long had the horse been in use at the site?___________________________ Was the horse in regular use prior to the incident?_________________________ What level(s) of rider(s) is the horse usually used for?_______________________ BRIEFLY DESCRIBE THE IMPORTANT DETAILS OF WHAT HAPPENED: ___________________________________________________________________________
Signed______________________________________________Date____________________ Person involved in incident. Signed______________________________________________Date____________________ Instructor in charge at time of incident. PLEASE PRINT THE NAMES/ADDRESSES & PHONE #’S OF INSTRUCTOR(S) ON THE BACK OF THIS FORM. |