Accident Replacement Form | Tipperary Equestrian

Thank you for taking the time to report your accident, or the accident of your loved one while wearing a Tipperary Equestrian product. We use these submissions for reaserch with the goal of improving rider safety.

IMPORTANT NOTE: In order to replace your helmet, you must follow the Accident Replacement Program instructions found here: Accident Replacement Program . This form only reports the details of your accident, and does not iniate a helmet replacement.

Tipperary Equestrian Accident Report

Date of accident *

Country *

Country where accident took place

Location of accident *

Example: Indoor arena, Outdoor sand ring, Paddock, Trail, In a Stall, In the barn aisle etc

Name of the person in the accident *

If you are filling out the form for the person in the accident, please put the accident sufferer's name here

Age Range *

Age of person involved in the accident

Gender *

Gender of person involved in the accident

Age of Horse (Years) *

Gender of Horse *

Height of Horse HH *

Activity Engaged in at the time of the accident *

Gait at the time of the accient *

Helmet or Body Protector Worn during the accident *

Helmet Size *

Date of Purchase *

Is the helmet visibly damaged *

Yes

Was an air vest worn during the accident? *

Yes

Was a body protector worn during the accident? *

Yes

Please provide a detailed description of the accident *

Please select any head injuries sustained from the accident *

None

Mild concussion

Moderate concussion

Severe concussion

Cerebral edema

Diffuse axonal injury

Skull fracture

Subarachnoid heamorrhage

Subdural hematoma

Was there any loss of consciousness? *

Was amnesia experienced? *

Was any loss of memory of the below time periods experienced? *

Were any face injuries sustained? *

Were any limb injuries sustained? *

Were any bodily injuries sustained? *

Did the person in the accient visit a hospital? *

Yes

Recovery Period *

How much time did the person in the accident have to take off of paid work? *

Please upload an image of the helmet worn during the accident in its current state *

Max file size: 10MB

Please upload any images of the accident

Accepted file types: jpg, gif, png, pdf, Max. file size: 16 MB, Max. files: 5.

Please include links to any videos of the accident

Please privately upload any footage you have available to YouTube, Vimeo or Dropbox in order to share it with us

Will the person in the accident be replacing the product involved? *

Yes

Your name *

Street address *

Address line 2

City *

State/Province *

Postal/Zip Code *

Country *

Your Email *

Telephone *

Please include any additional comments or feedback

Do you consent to sharing your story to help rasie awareness of rider safty? If so, we will contact you to arrange details before your story is shared.

Yes

Would you like to receive emails from Tipperary Equestrian?

Yes

I consent that the above details can be used in accordance with the privacy policy.

Separate email addresses with a comma.

Submit

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