Non Collision Incidents Survey

1. Who are you completing this form for?: *

2. Age of the cyclist at the time of the incident?: *

3. Was the rider injured or hurt?: *

4. When did it happen?:

4. Or...:

Not Sure

5. Why was the person cycling at the time of the incident?: *

6. Where did it happen?: *

7. Were the police aware of the incident?: *

8. What sort of bike was being ridden?: *

9. What was the weather like?: *

10. What was the main cause of the incident?: *

a. Lost control or slipped

b. Vehicle defect

c. Swerved to avoid something

d. Something fell or got caught in the wheels, chain, gears

e. Rider was distracted or impaired

f. Other (please tell us in your own words in the box below)

Please only complete just one of 10a, 10b, 10c, 10d, 10e or 10f below.

10a. Lost control or slipped:

10b. Vehicle defect:

10c. Swerved to avoid...:

10d. Somthing fell or got caught in wheels / chains / gears:

10e. Primary Cause - Rider distracted or impaired by:

10f. Other:

11. At the time of the incident, how long had the cyclists held a full UK driving licence?: *

12. How long had the rider been able to ride a bike at the time of the incident?: *

13. What cycle training had the rider had: *

14. How would you describe the way the brakes and gears were maintained?: *

Can we contact you?: *

Yes

Email address:

Name: *

Address:

Postcode: *

Ethnicity:

How do you describe your ethnicity?

Gender:

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