Intramural Injury Report Form
This form should be submitted if an intramural member got injured during a competition. This includes suspected sprains, strains, concussions, fractures, etc.

This can be submitted by the injured person or by a fellow club member.
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Intramural Sport *
Name of Injured Person *
Email of Injured Person
Phone Number of Injured Person
ID Number of Injured Person
Affiliation of Injured Person
Clear selection
Where did the injury occur?
State which facility.
Date/Time of Injury
List date and approx time
Part(s) of body injured *
How did the injury occur? *
Brief description of teatment/first aid/care given at time of injury
Was an ambulance called? *
If ambulance was called, was injured person transported to hospital?
Clear selection
Has injured person gone to MIT Medical?
Clear selection
Name of person submitting form
(if different from injured person)
Email of Person Submitting Form
(if different from injured person)
Phone Number of Person Submitting Form
(if different from injured person)
Available Medical Resources On Campus
- MIT Medical: http://medweb.mit.edu  Urgent Care is open every day from 7am-11pm.  This should not be used in lieu of emergency services, but it’s probably the quickest way to get connected to a medical professional in a non-emergency situation.  

- MIT Together: http://together.mit.edu  This site connects you to a variety of resources, both academically related and personally related.
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