Click on Form Name for Hard Copy Member Concern Request for ReviewInjury / Incident ReportCommittee Formation ProcessRide Committee ResponsibilitiesMulti-Day Ride Form & ProcessSag Van Check List Electronic Forms Posted Below Member Concern Request for Review Instructions for Submission It is expected that Members report any concern directly to the Ride Leader for immediate resolution. A Request for Review should only be submitted if this is not possible or the concerns have been conveyed but not addressed. All details must be provided, including the Members name and contact information, witness names and details of the concern and/or incident resulting in the concern. Please select the Concern Type from the dropdown box. Health & Safety (OCC policies not followed) Ride Practices (Ride Policies not followed) Incident (occurance related to above or separate and not reported) Personal Member Information * Must be completed to be reviewed. Further information may be requested from the Member by the Review Committee. First Name Last Name Address * Phone * (###) ### #### Email * Incident Details and Date. * Date of the Incident. * MM DD YYYY Time of the Incident. * Hour Minute Second AM PM Was the Incident reported to the Ride Leader. * Yes No If No, please explain why the Ride Leader was not informed. * Was the Incident reported to a Board Member. * If Yes, Board Members Name. Were witnesses or others involved in this Incident. * Witnesses may be approached for further information to assist with the investigation. Yes No If Yes, provide the name and contact information. * If any additional details required, please document below. * Yes No Please ensure any additional concerns are documented below. Form Completed by. * Thank you! Injury / Incident Report Injury / Incident Type Please select the Injury or Incident Type from the dropdown box. Medical Aid (Services provided by a health care practitioner) First Aid Only (A minor Injury with only on site treatment) Near Miss / Incident Only (An incident, but no injury). Property Damage (An incident that only results in property damage) Personal Member Information * Must be completed to be reviewed. Further information may be requested from the Member by the Review Committee. First Name Last Name Address * Phone * (###) ### #### Email * Date of the Injury / Incident. * MM DD YYYY Time of the Injury / Incident. * Hour Minute Second AM PM Type of Injury / Incident. * check all that apply from the dropdown options. Struck Fall Overexeertion Motor Vehicle Incident Property Damage Other Describe what happened to cause the Injury / Incident * Describe the environment at the time of the Injury / Incident * Describe the nature of the Injury / Incident * Describe what First Aid treatment was administered, if any. * Location where the Injury / Incident happened, including the address. * If No, please explain why the Ride Leader was not informed. * Were witnesses or others involved in this Incident. * Witnesses may be approached for further information to assist with the investigation. Yes No If Yes, provide the name and contact information. * If any additional details are required, please document below. Health Care. * Was external treatment provided? Yes No Where was treatment provided? * Check all that apply Ambulance Emergency Dept. Admitted to Hospital Other If any additional details required, please document below. * Yes No Did any Vehicle/Property contribute to the Injury / Incident? * Yes No If Yes, how? Type of vehicle/property. Add additional details below. Environmental Conditions. Did the condition of the physical surroundings (Weather, road conditions) contribute to the Injury / Incident. Yes No If Yes, add details below. * Form Completed by. * Follow up * Is a Follow up investigation required? (To be completed by the Safety Committee) Yes No Thank you!
