Near Miss & Crash Reporter

Privacy Policy

Bicycle Network understands and values your privacy.

Details about your crash or near miss will be used to help improve bike riding in Australia and personal information will only be used as per Bicycle Network’s privacy policy.

Read our privacy policy.

Demographics

Are you a Bicycle Network Member?

What is your rider number?

What is your gender?

Age group

What type of bike you were riding at the time of the incident?

If other type, please specify

How often do you ride for each the following purposes:

Location of incident

Scroll and zoom in on the map to find the area of your incident, then click on the exact location.
A red marker will appear and will save the incident location.

Latitude

Longitude

Home post code

How far were you from home when the incident happened?

0 to 3 km3 km to 5 km5 km or 10 km10 km or more

What happened and when?

What was the date of the incident?

What was the approximate time of the incident?

Hour

Minute

Which of the following best describes the type of incident?

Near-miss with a motor vehicleCollision with a motor vehicle (car, motorbike, truck, car door, stationary or parked car, etc.)Collision with something other than a motor vehicle (bike, pedestrian, tree, curb, street sign, etc.)Lost control and fell down or off bike

Was a vehicle involved with the incident which caused your collision or that caused you to lose control?

YesNo

About the location

Other

Which of the following best describes the intersection?

4-WAY INTERSECTIONT-INTERSECTIONROUND-A-BOUTOther (specify)

Other Details

Other details

Did this contribute to the incident? Please select one answer per row

	Yes	No	Not Sure
Pot holes
Cracks that run in the same direction of travel
Cracks across the direction of travel
Bumps in the surface
Rough surface
Loose stones
Green bike lane paint
Painted lines and symbols
Icy surface
Wet surface
Muddy surface
Oil/petrol
Leaves, branches or other vegetation
Tram/train tracks

Other details

What type of bike infrastructure did the roadway have?

No bike lane or rideable shoulderNo bike lane, but a rideable shoulderBike lane (painted line)Bike lane with green painted surfaceBike lane with physical separation from other trafficOther (specify)

Did the intersection have traffic lights?

YesNo

In the direction you were travelling, which of the following colour were the traffic lights?

GreenOrangeRedNot sure

In the direction you were travelling, did the intersection have a dedicated left turning lane for cars?

YesNoNot Sure

Loss of income or damage of property

Did you take time off work as a result of the incident?

Yes – I haven’t gone back to work yetYes – but I’m back at work nowNoI was not working at the time of the incident

How many days did you take off work as a result of this incident?

How many days have you had off work so far?

What are your approximate out-of-pocket expenses so far for each of the following items relating to the incident? ‘Out-of-pocket’ means money you have spent that you don’t get back through Medicare or insurance


Ambulance (if you have ambulance cover enter 0)	$
GP (non-bulk billed component)	$
Specialists (physio, osteo, etc)	$
Loss of earnings	$
Repair or replacement of your bike	$
Repair or replacement of your clothing	$
Transport, including taxi or public transport costs for trips you would have otherwise done by bicycle	$
Other (specify)	$

Other Information

Would you be willing to participate in follow-up research about your incident and how it has affected your riding?

YesNo

Privacy Statement and link. Please enter your name and email

Name

Email

Please use the box below to describe anything else about the circumstances that led to the incident, or afterwards, that you’ve not yet described that you think are relevant.

Thank you for completing our Near Miss and Crash Reporter. Please note - if you are a Bicycle Network member and wish to make a claim, please call 1800 639 634.
Privacy Policy

Bicycle Network understands and values your privacy.

Details about your crash or near miss will be used to help improve bike riding in Australia and personal information will only be used as per Bicycle Network’s privacy policy.

Read our privacy policy.

	Every day	A few times per week	A few times per month	A few times per year	Never
Errands
Commute
Recreation/Leisure
Sport/Exercise