Alberta Velodrome - Injury-Accident- Report

Injury-Accident Report Form

Name of the first responder, track monitor or coach

First name *

Last name *

Email *

Mobile

Please complete this form in full (one per incident) within 12 hours of the incident.

Minor Accident: A situation that could have caused injury or damage but did not.

Superficial injury (scrape, bruise, or minor fall).
Minor mechanical failure with no injury.
Incident resolved by AVA staff on-site with first aid
Rider sliding down the track with no injury

Major Accident: Injury requiring medical treatment beyond basic first aid.

Collision involving multiple riders or high speed.
Equipment needed to be fixed or replaced, (bar tape, tube)
Damage to facility or equipment affecting operations.
Any situation requiring COE emergency response or participant needs further examination

Was this a Major incident? *

No Yes

What program was on at the time?

i.e.Team Track, Youth Program, Camp, School Visit

What was damaged?

Helmet Bike Tires Clothing Other Track (Please fill Track Damage Report)

Other

Individual Experiencing Injury Information:

The information is needed for reporting and follow up.

First name *

Last name *

Email *

Mobile *

Date of birth *

Address

City

Country

State/Province

Zip/Postal code

Damaged Areas

What Track Meter Mark?

Fill out following Injury Report

Download and fill out then re-upload here.

Injury Report

Date & Time of Injury/Accident *

How did the incident occur? *

Contact with another rider Loss of Control Mechanical Failure Rider Error Not riding fast enough Pulled foot

Other

Please provide details on how the incident could have been prevented? *

Action Taken

Provide details on how the injured was assessed? *

Name of hospital / clinic (if applicable)

Transported by:

Who was the Emergency contact?

What time were they contacted?

Who were they Informed by:

Coach Staff Other

First and Last Name

Electronic signature*

Please sign your name inside the box