FIRST REPORT OF OCCURRENCE □ Annual License Rider □ National Team Rider □ One Day Rider Return to: USA , Inc. □ Road □ □ BMX Race □ Pro 210 USA Cycling Point □ Track □ Cyclocross □ BMX Freestyle □ Para □ Collegiate Colorado Springs, CO 80919-2215 Ph: 719-434-4200 _____Number of Riders _____Number of Officials _____Number of Event Staff Fax: 719-434-4300 In case of serious accident or injury, notify USA Cycling Date of Incident: ______Event Name: ______Permit #: ______Time of Incident: ______Event Organizer’s Name:______Date of Event: ______Promotion Club(s): ______This accident occured: Was the injured person wearing a helmet at the time of the accident? □ YES □ NO □ Before Event □ During Event Was the injured person riding: □ Single Bike □ Tandem Bike □ After Event □ Practice Waiver and Release signed? □ YES □ NO □ Set-Up □ Travel (If “yes”, attach the original waiver to this form before mailing and retain a copy of both documents for your files.) INJURED PERSON INFORMATION: □ Participant □ Volunteer □ Pedestrian □ Official □ Spectator □ Other: ______Last Name:______First Name:______MI:______Phone #: ______Address:______SSN: ______City:______State:______Zip:______Gender: □ Male □ Female Age:______DOB:______Category:______USAC #:______Employer: ______Does this person have insurance? □ YES □ NO If “yes”, insurance company/policy: ______TYPE OF EVENT WEATHER CONDITIONS ROAD CONDITIONS □ Road Race □ Mountain □ Track □ Non-competitive □ Sunny □ Wet □ Dry □ Ice □ Open Course □ Cross Country □ Cyclo-cross □ Gran Fondo □ Raining □ Other: ______□ Closed Course □ Downhill □ Clinic □ Foggy □ BMX Race □ Rolling Closure □ Observed Trials □ Training Ride □ Snowy ROAD TYPE □ Criterium □ Mountain Cross □ BMX Freestyle □ Camp □ Cloudy □ Paved □ Gravel □ Stage Event □ Enduro □ Extreme Temp □ Dirt □ Asphalt □ Time Trial □ Fat Bike □ Hail □ Off Road INCIDENT LOCATION RIDER ACTIVITY CAUSE □ Off-Road □ Highway □ Turning right □ Assault/sexual □ Struck by falling/flying object □ Parking Lot □ Off Property □ Turning left □ Assault/non-sexual □ Collision (with parked car) □ City Street □ Being Passed □ Fall (different elevation) □ Collision (with moving car) □ Rural Road □ Passing □ Fall (same elevation) □ Collision (with object/animal) □ Registration Area □ Intersection □ Caught in, on, or between □ Collision (participant/participant) □ Restroom/Locker Room □ Strait □ Overexertion □ Collision (participant/pedestrian) □ Premises/Grounds □ Animal involvement □ Collision (participant/spectator) □ Velodrome/Track □ Equipment failure □ Auto/Property (also complete next page)

CLASSIFICATION BODY PART INJURED □ Non-injury □ Eye L R □ Hand L R □ Wrist L R □ Foot L R □ Head □ Mouth □ Torso □ Back □ Internal □ Minor injury or illness □ Ankle L R □ Arm L R □ Shoulder L R □ Leg L R □ Face □ Neck □ Tooth □ Nose □ Finger/Toe □ Serious injury or illness □ Knee L R □ Hip L R □ Elbow L R □ Ear L R □ Other______PRIMARY INJURY □ Allergy/Sting □ Abrasion □ Nausea □ Burn □ Electrical Shock □ Dislocation □ Pain □ Amputation □ Concussion □ Cold Injury □ Tooth/Mouth □ Seizures □ Foreign body □ Strain/Sprain □ Cardiac □ Stroke □ Heat Exhaustion □ Fracture □ Hypertension □ Drowning □ Laceration □ Contusion □ Death □ Illness DISPOSITION □ Report only □ Medical Attention □ Patient requested EMS transport □ Released to parent □ Ambulance □ Continued riding □ Police □ Refer to doctor □ Released to personal vehicle □ Refer to hospital/clinic □ EMS transport □ Refusal of care

DESCRIBE HOW THE INCIDENT OCCURED: ______

Printed Name of Chief Referee or Official: ______Phone:______Date:______Signature of Chief Referee or Official: ______Witness (with no relation to claimant) Name: ______Phone:______Email:______Address:______