Injury Reporting

Name of Injured Person *

Date of Injury *

Team *

Position *

If other, please specify

Location Injury Occurred *

If other, please specify

Activity When Injury Occurred *

If other, please specify

Type of Injury *

If other, please specify

Body Parts/Regions Injured *

Nature of Injury/Illness * (select all that apply)

If other, please specify

Provisional Diagnosis *

Mechanism of Injury * (select all that apply)

Struck by another player Struck by ball or stick Collision with player/umpire Collision with fixed object Slip/trip/fall Overexertion/overuse Temperature related (e.g. heat stress) Other

If other, please specify

Explain How the Incident Occurred *

Were There Any Contributing Factors? *
(e.g. unsuitable footwear, foul play, playing surface, etc.)

Was Protective Equipment Worn on the Injured Body Part? *

Yes No

If yes, what protective equipment? (e.g. mouthguard, shin pads, etc.)

If no, why not?

Initial Treatment Given (select all that apply)

If other, please specify

Advice Given

Referral

If other, please specify

Provisional Severity Assessment

Name of Treating Person

Qualification of Treating Person

If other, please specify

Signature of Treating Person

Date Completed

Fields

Injury Reporting

Injury Reporting Form

Injury Reporting Form