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Near miss head on

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Incident date*
DD slash MM slash YYYY
Incident time

: HH

MM
Incident type*
- Crash
- Close call
- Close pass/Bad driving
- Bad road/path
- Animal encounter
Type of Crash
- Animal
- Bike
- Motor vehicle
- Obstacle
- Other
- Solo
Type of Close call
- Animal
- Bike
- Motor vehicle
- Obstacle
- Other
- Pedestrian
- Road condition
- Solo
Type of Bad road/path
- Bad path
- Bad road
- Blocked bike path
- Dangerous intersection
- Obstacle
- Other
Type of Close pass
- Bus
- Car
- Motorbike
- Other
- SUV
- Truck
- Ute
- Van
Type of Animal encounter
- Bees
- Bird
- Cat
- Cow
- Coyote
- Crocodile
- Deer
- Dog
- Goanna
- Horse
- Jackal
- Kangaroo
- Monkey
- Other
- Peacock
- Pig
- Rabbit
- Sheep
- Skunk
- Snake
- Squirrel
- Wombat
Injuries suffered
- No Injury
- Minor
- Moderate
- Serious
- Fatal
Vehicle registration plate
*
- I’ve read and accept the terms & conditions, and I consent to Upride on behalf of Cycliq storing and managing my data.

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