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RUSA Voluntary Accident Reporting System

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RUSA Voluntary Accident Reporting System

If you were involved in an accident serious enough to require a hospital visit or to obtain other significant medical services during a RUSA event, please fill in this form and submit it to RUSA.

A copy of your report will be sent to RUSA's Safety Coordinator, the event organizer (RBA) or permanent route owner, and RUSA's Board of Directors. The RBA or route owner will have the opportunity to add a statement to your report but cannot otherwise modify any part of your submission.

By submitting a report, you give RUSA permission to disseminate a summary of your accident to its members, its insurance carrier, or the general public. Your name, RUSA member number, and all other personal identifying information will be removed from any summarization that RUSA might produce.

RUSA's intent is to collect and summarize the facts about accidents rather than attempt to assign or determine fault. RUSA's Board of Directors believes this will help enhance the safety of RUSA events by providing additional information about accidents. The basic principle is that riders are self-sufficient and responsible for their own safety; these reports will assist riders as they make their own decisions about risk.


Information about you, the accident victim
RUSA member Non-member
Member number
Name
Gender M    F
Age

Information about the ride
Ride Type
Region (skip for permanents)
Date YYYY/MM/DD
Distance (km)
Permanent Route # lookup (skip unless permanent)

Information about the accident
Bicycle Used e.g., single, recumbent tandem
Time of Day HH:MM, in 24-hour time
Distance Completed (km) (e.g., 100, if the accident occurred halfway through a 200km event)
Briefly Describe What Happened
Injuries Sustained
Contributing Factors


Revision: December 21, 2014
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