ACCIDENT/INJURY REPORT FORM

ACCIDENT/INJURY REPORT FORM
Accident/Injury Report Form for all breeds and disciplines
except Eventing.
Submit form to: [email protected] or fax 859.231.6662
UNITED STATES EQUESTRIAN FEDERATION
4047 Iron Works Parkway • Lexington, KY 40511 • Phone: 859.258.2472 • Fax: 859.231.6662
This section is to be completed by the Steward/Technical Delegate who should note the circumstances as indicated on the form and also provide information regarding
responders, EMS providers and the medical facility transported to (if applicable) so that the medical records can be located if required.
URGENT - Contact USEF immediately and include a copy of the entry form with report! Weekend Emergency Number is 859.312.5186
Please check if:
□ FATALITY □ SERIOUS INJURY
INCIDENT DESCRIPTION
□ POSSIBLE HEAD INJURY Submit report by 6pm the day following the end of the competition. □ OTHER INJURY
1. Injured: □ Person □ Horse □ Both (fill out one form for each)
Accident Date:
Injured Person:
Age:
□ Junior □ Senior
2. Injured Horse:
Age: ______________
Sex:
□ AM □ PM
USEF Membership #:
Sex of Person: □ F
Category of Participation: □ Rider
Time:
□ M Emergency Contact Information:
□ Handler □ Groom □ Spectator □ Official □ Visitor □ Volunteer □ Ring/Jump Crew □ Other: _________ ________
□ Mare □ Gelding □ Stallion □ Colt □ Filly
USEF Membership #:
3. Competition Name: ______________________________________________________________ USEF Competition #:
4. Location where injury occurred:
□ Cross-Country Course □ Show Ring □ Dressage □ Warm-up Ring □ Stabling □ Parking □ Other:
5. Name and type of class (must complete if accident happened during or in preparation for a class):
6. If over fences (must complete if applicable) specify: type of JUMP
and HEIGHT
Safety cups? □ Yes
□ No □ N/A
Frangible (cross-country) □ Yes □ No □ N/A
Rotational Fall: □ Yes □ No
8. Footing:
□ Indoor □ Outdoor □ Sand □ Dirt □ Grass □ Artificial □ Natural
□ Other:
Footing Condition: □ Deep □ Heavy
□ Slippery □ Good □ Firm □ Hard □ Rough/ Rugged □ Other:
Weather:
□ Sunny □ Cloudy □ Raining □ Windy □ Foggy □ Snowing □ Extreme Temp. □ Artificial Light
9. Protective Equipment Worn:
ASTM/SEI Helmet: □ Yes □ No
Unapproved Helmet: □ Yes □ No
Body Protecting Vest: □ Yes □ No □ N/A
Inflatable Vest: □ Yes □ No □ N/A
Other:
7. Fence Safety Features:
10. Describe nature of injury/narrative:
11. Name of witness (other than Steward/TD):
Phone #:
This section completed by:
Date:
TREATMENT INFORMATION
This section to be completed by the Steward/Technical Delegate, or medical personnel or veterinarian who treated the patient.
□ On-site □ Transported (Ambulance) □ Transported (other) □ None
□ Refused Transport □ Refused Treatment 14. Treated by: □ EMT/ Paramedic □ Physician trained in pre-hospital trauma care □ Nurse trained in pre-hospital trauma care □ Veterinarian
□ Spectator □ Official □Other: _________________________________________________________________________________
13. Treatment:
15. Describe treatment:
© 2012 by United States Equestrian Federation® All rights reserved. Reproduction without permission is strictly prohibited.
White Copy goes to USEF
Yellow Copy goes to Organizer/Manager
Green Copy goes to Steward/TD
Injured Person/Horse:
Date:
REFUSAL OF EVALUATION
□ I refuse to be evaluated by the qualified medical personnel at this competition. Per General Rule 1316 concerning Return to Competition and Accidents Involving
Competitors, by refusing to be evaluated by the qualified medical personnel at this competition, I am disqualified from the remainder of this competition. I understand that I will be placed on the Federation Medical Suspension List and will not be eligible to compete at any future USEF licensed or endorsed Competitions until
I submit appropriate medical release documentation as required by the Federation through General Rule 1316.
By marking the box above and signing here I acknowledge that I understand I will be disqualified and placed on the Federation Medical Suspension List as
detailed above.
Name: _____________________________________________________________________________ Membership #:
Signature:
Date:
INJURY INFORMATION
16. Possible Concussion/Head Injury:
17. Suspected type of injury:
□ None □ Other:
□ Yes □ No
□ Yes □ No
□ Muscle and Tendon □ Contusions □ Lacerations and Skin Lesions
If yes was person cleared to return to competition?
□ Fractures and Bone Stress □ Joint (Non-Bone) and Ligament
18. Name of On-site treating EMS personnel/veterinarian (if applicable):
Phone #: _______________________
19. Name of EMS Provider(s) (Ambulance, Helicopter, etc.):
_ Phone #: _______________________
20. Facility patient transported to:
Phone #: _______________________
21. Please circle all injured area(s) on the models illustrated below.
Front
Back
Right Side
Left Side
ADDITIONAL MATERIALS
□ Yes (please attach) □ No
Include clearance to return to competition, if applicable? □ Yes (please attach)
□ No
Did you call report in to USEF? □ Yes □ No
□ N/A
Did you obtain eyewitness reports?
If yes, date and time called in:
□ N/A
To whom:
Steward/Technical Delegate’s name:
USEF Number:
Steward/Technical Delegate’s signature:
Did the Steward/TD witness the incident?
Date:
□ Yes □ No
Safety Officer/Coordinator’s name:
Phone Number:
Safety Officer/Coordinator’s signature:
Date:
© 2012 by United States Equestrian Federation® All rights reserved. Reproduction without permission is strictly prohibited.
White Copy goes to USEF
Yellow Copy goes to Organizer/Manager
Green Copy goes to Steward/TD