PAGEMILL PASTURES

3450 Deer Creek Rd., Palo Alto, CA† 94306

 

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

Personís riding style when incident occurred:

††††††††††† English______Western______Bareback_______Trail ride________Other________________

Personís 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?_________ Instructorís 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 #íS OF INSTRUCTOR(S) ON THE BACK OF THIS FORM.