INCIDENTREPORTFORM InjuryorPropertyDamage

INJUREDPERSONINFORMATION/ PROPERTYDAMAGEOWNER

LastNameFirstMiddle / Telephone / †Single†Married
†Male†Female
Address / Employerand Address
Date ofIncidentTime ofIncidentam/pm / DateofBirth
INJURED PERSON: †Participant†Official†Coach
†Spectator †Volunteer†Other: / EVENT: †
NAMEOFEVENT: ClubName: / Does theinjured person haveothermedicalinsurance? †Yes
†No
Ifyes,pleaseprovidenameofcompanyandpolicy#:

GUARDIAN/PARENT (IF INJURED PERSON IS A MINOR)

Name

Address,City,State,Zip

Telephone

INCIDENT INFORMATION

BODY PART INJURED
†Ankle(L/R)†Shoulder(L/R) †Back
†Knee(L/R)†Wrist(L/R)†Neck
†Nose†Finger†Internal
†Head†Eye(L/R)†NoInjury
†Tooth†Ear(L/R)†Other / If AnkleInjury,was ankle:
†Taped†Supported
†Unsupported
Shoes:†Yes†No
If KneeInjury,was knee:
†Braced†Supported
†Unsupported
KneePads:†Yes†No / INCIDENT OR PROPERTY DAMAGE
†Collision(participant/spectator)
†Collision(withobject)†Slip/Fall
†Collision(participant/participant)†Overexertion
†Collision(spectator/spectator)†Assault/Sexual
†Struckbyfalling/flyingobject†Assault/Non-Sexual
†Caughtin,on,between†PropertyDamage
†Animal/insectbite/sting
SURFACE
†Concrete †
Asphalt
†Grass†
†Wood
Other / INCIDENT LOCATION
†BeforeCompetition/Event
†DuringCompetition/Event
†AfterCompetition/Event
†Competitionarea
†Concession area
†Parkinglot
†Admissionarea
†Restrooms/lockerrooms
†Offproperty
†Bleachers/stands / PRIMARY INJURY
†Allergy†Dislocation
†Amputation†Nausea
†ForeignBody†Burn
†Laceration†Fracture
†HeatExhaustion†Pain
†Hypertension†Cardiac
†ColdInjury†Contusion
†ElectricalShock†Seizures
†Strain/Sprain†Concussion
†Abrasion†Sting/bite
†Illness†Death / DISPOSITION
Nocaregiven:†Patientrefused
†Notneeded
Released:†Toparent
†Topersonalvehicle
Referral:†Todoctor
†Tohospital/clinic
EMStransport:†Trainerrecommended
†Patient/parentrequested
CLASSIFICATION
†Non-injury
†Minorinjuryorillness
†seriousinjuryorillness
Describehowtheinjuryorpropertydamageoccurred:(attachaseparatesheetifnecessary)

WITNESS INFORMATION

Name / Address / TelephoneNumber
1.
2.

EventDirector,Event official, Event Volunteer, or other personcompletingthis form:______

Name: Signature: Title: Date: Phone#:()