Bicycle Incident Report
Please fill out one report per incident occurrence and fill in as much information as possible
Section A. General Information
Today's Date:
Your Name:
Your Street Address:
Your City:
Your Telephone:
Are you a:
Your zip code:
NC
Your email:
Commuter
Recreational Rider
Racer
Other (please describe):
Section B. Incident Information
Date of Incident:
Street name/landmarks for location on road:
Time of day:
AM
PM
Weather conditions:
Were you riding alone?
Yes
No
Number of lanes on street:
Were you in a bike lane?
Yes
No
Were you on a sidewalk?
Yes
No
Lighting Condition:
dusk
dawn
daylight
darkness with street lighting
darkness without street lighting
other (please describe):
Traffic volume:
Road Configuration:
Road Feature(s):
none
light
one way
moderate
two way
4-way intersection
hill crest
heavy
Divided Highway
T-intersection
blind curve
side street
other (please describe):
private drive
parking lot
railroad crossing
Section B. Incident Information continued
You were:
riding with traffic
stopped at an intersection
riding against traffic
Equipment in use:
headlight
making a left turn
making a right turn
other (please describe):
tail light
reflector
vest/banner
other (please describe):
Did you file a police report?
yes
no
If "yes", what type of report was filed and what was the report number?
Report number#
Was this incident involving a vehicle, motorized or non-motorized?
yes
no
If "yes" please proceed through section C. If "no", please go to section D
Section C. Incident Involving another vehicle
Please describe
the incident:
Please describe
any information
about the
vehicle:
Please describe
any information
about the driver
(sex,
approximate
age, etc.):
Accident
Offense
Section D. Non-Vehicular Incident
The non-vehicular incident involved (please check and describe):
Signage
Broken Pavement
Animal(s)
Landscaping
Railroad Tracks
Road Hazard (please describe the hazard):
Other (please describe):
Please describe
what occurred
during this
incident:
Section E. Additional Information
Please include
any additional
comments such
as what can be
done to prevent
this incident
from occurring
again:
Would you be interested in receiving future updates on bike and pedestrian events and meetings via email?
yes
no
You may submit this form electronically by clicking the "Submit by Email" button below or you may print this form by clicking
the "Print Form" button then mailing the printed form to:
Incident Report
% Liberty Bicycles, Inc
1378 Hendersonville Hwy
Asheville, NC 28803
Submit by Email
Print Form