USA TriathlonReport an Incident

USA Triathlon

Report an Incident

If you are aware of an incident that may give rise to a liability claim under this policy, you are required to report this information immediately using this form.

Event Name*

Date of Incident*

Time of Incident

Participant Accident Incident

Check this box to complete this section if a participant, spectator or volunteer was injured during this event.

General Liability Incident

Check this box to complete this section if a third party was injured or had property damage sustained during this event.

Injured Party's Information

Injured Party's First Name*

Injured Party's Last Name*

Injured Party's Race Number (Bib Number)*

Injured Party's Phone Number*

Phone

Injured Party's Email Address*

Injured Party's Date of Birth*

Injured Party's Gender*

Male

Female

Other

Other

Type of Injury*

Minor Incident (i.e., any injury treated by medical staff at venue)

Serious Injury (i.e., any injury that requires transport by ambulance off race course or venue). This requires notice to Brad Hildebrandt at USAT.

Fatality

Event Details

Type of Event Where the Incident Occurred*

USA Triathlon Sanctioned Event

IRONMAN - USA Triathlon Sanctioned Event

USA Triathlon Official Club Event

USA Triathlon Sanctioned Clinic

Team USA International Event

Did this take place during*

Select

If During Competition, Which Discipline*

Select or enter value

Other

Please describe

Incident Details

Incident*

Select

Other

Please describe Incident:

Primary Injury (Chief Complaint)*

Select

Other

Please describe primary injury:

Primary Injury Location*

Select

Other

Please describe primary injury location:

Services Provided*

Select

Other

Please describe services provided:

Incident Location*

Select

Other

Please describe incident location:

Classification*

Select

Injured Person*

Select

Other

Please describe injured person:

Describe How the Incident Occurred*

Treated By:*

Provide Report Number (If Known)*

Did the Participant Refuse Care?*

Yes

No

Property Damage

Did Property Damage Occur?*

Select or enter value

Description of Damaged Property*

Name and Contact Information of Property Owner*

Any Additional Details to be Provided*

Witness Information

Did you obtain contact information for any witnesses?

Select

Full Name of Witness #1

Phone Number of Witness #1

Phone

Email Address of Witness #1

Were there any additional witnesses?

Select

Full Name of Witness #2

Phone Number of Witness #2

Phone

Email Address of Witness #2

Full Name of Witness #3

Phone Number of Witness #3

Phone

Email Address of Witness #3

Emergency Contact Information

Emergency Contact Full Name*

Emergency Contact Phone Number*

Phone

Emergency Contact Email Address*

Emergency Contact Relationship to Patient*

Contact Information of Individual Reporting Incident

Name of Individual Reporting Incident*

Phone Number of Individual Reporting Incident*

Phone

Email Address of Individual Reporting Incident*

Race Director Information

Race Director's Name*

Race Director's Phone Number*

Phone

Race Director's Email Address*

File Upload

File Upload

(Any reports, photos, estimates, etc may be attached to this record)

Drag and drop files here or

Acknowledgement of Individual Reporting Incident*

I hereby warrant that the foregoing is true and correct based on my knowledge of the incident by entering my name in the box below.

Send me a copy of my responses

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