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Obra Medical Occurrence Form

This document is an OBRA medical occurrence form used to report injuries that occur at OBRA races. It collects information about the injured party such as their name, address, and injuries as well as details about the race such as the date, location, and weather conditions. The form is to be filled out by the chief referee and first aid provider and returned to OBRA to document any medical incidents at OBRA sanctioned events.

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Tracy Ross
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18 views2 pages

Obra Medical Occurrence Form

This document is an OBRA medical occurrence form used to report injuries that occur at OBRA races. It collects information about the injured party such as their name, address, and injuries as well as details about the race such as the date, location, and weather conditions. The form is to be filled out by the chief referee and first aid provider and returned to OBRA to document any medical incidents at OBRA sanctioned events.

Uploaded by

Tracy Ross
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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OBRA MEDICAL OCCURRENCE FORM

ATTACH ORIGINAL RELEASE TO THIS FORM AND


RETURN TO
OBRA
PO BOX 5773
Salem, OR 97304
Top portion to be filled out by CR
Chief Ref:
Race Name______________________________________________________________
Date of Race__________________Time of Accident________am pm
Injured Party is:
Rider_______Official_____Spectator_____Volunteer_____Other,(describe)________________
Injured riders full name ____________________________________________________
OBRA bib or license number ________ (if annual member)
Complete home address________________________________________________________
Phone____________________ DOB_______________ SEX: Male Female
If transported which hospital were they taken to?
Promoters Name____________________ Promoters Phone __________________________
Accident occurred before race_____ during event____ after event_____
HELD ON:
Public Roads (Open)____Public Roads (Closed)____Public Road (Rolling Enc)_____
OFF-Road_____ Private Road____
WEATHER: Clear____Overcast____Rainy____Foggy____Temperature___________
ROAD CONDITIONS (at time of accident): Wet____Dry____Asphalt____Concrete_____Dirt_____
No. of Lanes______
Were barriers involved in the accident: YES NO If yes describe barriers___________________________
Was equipment failure a factor: YES NO
Did the accident involve a collision? YES NO If yes, with what_______________________________

To be filled out by first aid provider


Injured riders full name ____________________________________________________
OBRA bib or license number ________ (if annual member)

Location and description of injuries


A= abrasions
C= contusions
F= fractures
T= tenderness
Description:

Provider Signature:
Print Name:
Fatalities must be immediately reported to OBRA at 503-302-4935. No exceptions.

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