For Postseason Injuries, Send Copy to Trainer of Injured Athlete and To

NAIA-ATA Injury Report

For postseason injuries, send copy to trainer of injured athlete and to:

Kristin Gillette , 1200 Grand Blvd., Kansas City, MO 64106, Fax: 816-595-8200

Host Institution Information

Host Institution:
Host Physician:
Tournament Event: / Sport:

Athlete Information

Name of Athlete:
Athlete’s Home Institution:
Age: / Sex: / M F / Year / FR SO JR SR

Injury Information

Injured Side: / R L / DOI: / Nature of Injury: / Acute Chronic Re-injury
Current Date:
Injured Region: / Thoracic spine
Elbow
Thumb
5 finger
Hip
Lower leg
2nd toe
3rd toe / Head
Lumbar spine
Forearm
2nd finger
Chest
Groin
Ankle
4th toe / Face
Shoulder
Wrist
3rd finger
Abdomen
Thigh
Foot
5th toe / C-spine
Upper arm
Hand
4th finger
Pelvis
Knee
1st toe
Specific Region:
Injury / Sprain 1
Strain 1
Dislocation
Fracture
Concussion 1
Neurotrauma
Heat exhaustion
Allergy / Sprain 2
Strain 2
Subluxation
Laceration
Concussion 2
Tendonitis/Bursitis
Heat stroke
Cold/flu / Sprain 3
Strain 3
Contusion
Spasm
Concussion 3
Heat cramps
Impingement
Other
Comments:
Injury Management / Athletic Trainer E.R. Refer to Physician
Athlete Status / Continue to play Out of 1/2 game Out of game Out of tournament

Attending Athletic Trainer

Name / Signature:
Institution

NAIA National Office • 1200 Grand Blvd., Kansas City, MO 64106 • 816.595.8000 NAIA-ATA Injury Report Form /10-10