Incident Report
This form is required to be filled out in the event of an injury to staff or student while on the property - and is ALWAYS required if a student falls from a horse, gets stepped on, etc.
Sign in to Google to save your progress. Learn more
Email *
First Name (impacted person) *
Last Name (impacted person) *
Date of incident
MM
/
DD
/
YYYY
The person involved in the incident was: *
If the person injured was a student, who was the instructor, or NA *
What horse was involved?  If not horse related put NA *
What time of day did the incident occur? *
Where did the incident take place? *
If riding, what gait? *
If riding, was the impacted person jumping at the time? *
If riding what is the skill level of the rider? *
Was inclement weather a factor?  *
If a riding accident, was the impacted person wearing a... *
Did the horse spook at something? *
What kind of aid was required? *
Was follow up care required? *
Describe what happened *
If applicable, describe extent of injuries
Name of staff managing report *
By checking this box, I, the staff person managing this report certify that the contents are accurate:
Age of impacted person: *
If under 18, was a parent or guardian present at the time of the incident? *
Name of Parent/Guardian if impacted person under 18
By signing here, I, the impacted person over 18, or the parent guardian of the impacted person under 18, certify that the contents of this form are accurate to the best of my knowledge
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Graham EQ. Report Abuse
Google Forms