Accident Survey

The Twin Cities Bicycling Club would like your help in collecting information regarding bicycling accidents which occur during Club rides. The data we collect will help us to identify safety issues for our ride leaders. If you have experienced an accident on a Club ride, your answers to this survey are important to our continued effort to promote rider safety. The more complete information you provide about your accident, the better we will be able to identify and target areas for safety intervention and/or emphasis. We would prefer that this Survey be completed by the rider(s) involved in the accident. If this rider does not respond to the Survey, it should be completed by the ride leader. An accident is considered an incident involving a single TCBC rider (member or non-member) or involving multiple parties, including at least one TCBC rider and another bicyclist, vehicle or pedestrian. If you have any questions about the survey, please contact the Safety Committee at safety@biketcbc.org.

Thank you for taking the time to complete this survey.

Sincerely, The TCBC Board

Accident Survey

State the name and TCBC member number of the person involved in the accident. If this person is a non-member state your address, telephone, number and e-mail address.
Date of Accident
MM slash DD slash YYYY
What approximate time did the accident occur?
What was the specific location (i.e. city, street name, trail name, intersection, etc) where the accident occurred?
What was the name of the ride?
What was the category of the ride?
Who was the TCBC Ride Leader?
Describe how the accident occurred to include weather, road or trail conditions and other parties involved.
If 911 was called, who responded to the call?
If there were injuries sustained by you, describe the injuries in detail.
If you received medical treatment, state where, when, from whom and the nature of the treatment received.
Was an Incident Report Form for Bodily Injury completed and sent to American Specialty Insurance for any riders injured in this accident? If other, please specify.
- Yes
- No
Other
State the name, telephone number, and e-mail address of the person completing this accident report if other than the person involved in the accident.
State any suggestions you may have that would prevent this type of accident in the future.
If you have any other comments or observations regarding this accident enter them here.
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Phone
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