District 3 - Injury and Concussion Reporting Tool

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Little League Alberta District #3

This form is for reporting any injuries or concussions within District 3 events and teams. Completion of this form will trigger reporting to multiple District 3 staff. The purpose of this form is to track incidents and be used to evaluate potential safety hazards, unsafe practices and/or to contribute positive ideas in order to improve safety. When an accident occurs, please obtain as much information as possible.

Utilizing and submitting this for does not in any way, shape or form replace the need to the affected party/parties to get their own medical assessment, evaluation and treatment.

Should the incident involve the head or neck region of the affected party/parties please ensure you properly log this incident under the Concussion Reporting and Protocols section of this form.

Email *

Your name: *

Your Phone # *

Is this a potential Concussion Incident involving contact to the head or neck? *

Please NOTE choosing Yes or Unsure will take you to a Digital Version of the CRT6 form to assist in assessing with any potential Concussion related symptoms and such. After utilizing that section please ensure you complete the Incident Details section following the Concussion section to ensure proper reporting of the incident to District 3.

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This form was created inside of Little League Alberta District #3 Foundation.

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