Equestrian Center Incident Report

I am reporting a(n):

Date of incident:

Time of incident:

Location within the Equestrian Center of incident:

Reason for visit:

Number of staff on duty at time of incident:

Name of staff involved in incident:

Number of patrons at time of incident:

Name of patron(s) involved in incident:

Name of witness(es):

Weather at time of incident:

Equipment involved:

Why did the incident occur?

If other, please explain:

Did the party involved receive medical care?

If medical care was provided, was care provided by facility staff?

If yes, Name(s) the person(s) who provided care and describe in detail the care given:

Was EMS/law enforcement called?

If EMS/law enforcement was called, by whom?

What time was EMS/law enforcement called?

Was the party involved transported to an emergency facility?

If yes, where?

If no, did the party involved return to the activity?

Please describe the incident:

If there was 3rd party responsibility, provide name(s) and describe their involvement:

Was there facility or equipment damage?

If yes, describe damage:

Additional comments:

By signing below, I hereby acknowledge that the information in this report is a true, accurate and complete account to the best of my personal knowledge and information obtained through the date of this report.

Date

Equestrian Center Incident Report

Equestrian Center Incident Report

Contact Info

Administration:

Ranch House:

Community Center:

Facility/Parks Emergency:

Park Rangers:

Waste Connections: