OrangeCounty Junior All American Football
INCIDENT REPORT
THIS IS NOT A MEDICAL CLAIM FORM * THIS IS NOT A MEDICAL CLAIM FORM
THIS IS A "FILL-IN" FORM USING MS.WORD DOCUMENT. DOUBLE CLICK GRAY BOX TO ENTER TEXT OR CHECK BOX.
CHAPTER: / TODAY'S DATE:This report to be completed by an authorized rep of the Chapter and a copy submitted to the OCJAAF COMMISSIONER’S OFFICE within 10-days of incident. What to report? Incidents involving general liability issues, first aid and major medical injuries involving players/cheerleaders, parents/spectators, coach/team staff, board or other official members of the chapter/conference. It is up to the individual Chapter/Chapter President to qualify what incidents shall be recorded. Utilization of this form is an internal procedure to ‘protect’ and ‘provide necessary documentation’ to the Chapter/Conference in case of legal or medical restitution from the insurance provider. Please record as much information as necessary. If additional space is needed, please use the reverse side of this form. THIS IS NOT A MEDICAL CLAIM FORM, FOR OCJAAF USE ONLY. Thank you.
TYPE OF INCIDENT: LIABILITY FIRST-AID MEDICAL MAJOR MEDICAL OTHER
DATE OF INCIDENT: / TIME OF INCIDENT:LOCATION OF INCIDENT:
INCIDENT REPORT FILED FOR PARTICIPANT:
PARTICIPANT NAME: / PHONE NUMBER:
MAILING ADDRESS:
PLAYER-CHEERLEADER PARENT-SPECTATOR COACH-TEAM STAFF BOARD/OFFICIAL
OTHER (EXPLAIN):
REPORT OF INCIDENT, WHAT HAPPENED? (USE PAGE 2 OF THIS REPORT FOR ADDITIONAL SPACE)
DESCRIBE FINAL RESULTS: (USE PAGE 2 OF THIS REPORT FOR ADDITIONAL SPACE)
PARAMEDICS WERE CALLED? YES NO / TRANSPORTED TO LOCALHOSPITAL, WHERE?
WERE PARENTS PRESENT? YES NO / WERE PARENTS NOTIFIED? YES NO
NAME OF "PRIMARY" INSURANCE CARRIER, IF ANY:
NO, THE PARTICIPANT DOES NOT HAVE PRIMARY INSURANCE COVERAGE.
INCIDENT REPORT COMPLETED BY: / NAME: / TITLE:
DAY PHONE: / EVENING PHONE:
CHAPTER ACKNOWLEDGEMENT & VERIFICATION
(REQUIRES PRESIDENT SIGNATURE) / PRESIDENT SIGNATURE:
DISTRIBUTION: Original to OCJAAF, Copy to Chapter, Copy to Player/Cheerleader Contract Sleeve FORM NO: 008
PAGE 1 of 2 Rev: May-18-2009
OrangeCounty Junior All American Football
INCIDENT REPORT
THIS IS NOT A MEDICAL CLAIM FORM * THIS IS NOT A MEDICAL CLAIM FORM
THIS IS A "FILL-IN" FORM USING MS.WORD DOCUMENT. DOUBLE CLICK GRAY BOX TO ENTER TEXT OR CHECK BOX.
CONTINUED FROM PAGE 1…
REPORT OF INCIDENT, WHAT HAPPENED? / DESCRIBE FINAL RESULTS:DISTRIBUTION: Original to OCJAAF, Copies to (1) Participant Contract Sleeve & (2) Parent FORM NO: 008