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B&W HEALTH & SAFETY - ACCIDENT REPORTING FORM
Section 1 - Accident Details
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* Indicates required question
Please state what happened:
*
Your answer
Date of Accident
*
MM
/
DD
/
YYYY
Time of Accident
*
Time
:
AM
PM
Site of Accident:
*
Your answer
Athletics Activity Type:
*
Long jump
Hammer
High Jump
Triple Jump
Discus
Javelin
Shot
Pole Vault
Sprint Hurdles
400m Hurdles
Steeplechase
Sprints
Track Endurance Activity
Wheelchair Event
Seated Throw
Fell/Trail Running
Road Running
Physical Preparation Training
Warm up activity
Cross Country Running
Other:
Category:
*
Property Damage
Slip / Trip / Fall
Sporting Injury
Struck by Object
Other:
Body Part Injured:
*
Choose
Mouth
Buttocks
Foot
Trunk - Disc
No physical injury
Chest
Upper Arm
Lower leg
Hip
Multiple Trunk
Toe(s)
Vertebrae
Internal Organs
Wrist(s) and Hand(s)
Eye(s)
Abdomen including groin
Wrist
Multiple Lower Extremities
Neck - multiple injury
Multiple Head Injury
Thumb
Skull
Insufficient Info to Properly Classify - Unclassified
Upper Back Area (Thoracic)
Lumbar and/or Sacral Vertebrae
Body Systems and Multiple Body Systems
Disc
Hand
Lower Arm
Shoulder
Upper Leg
Ankle
Arm
Knee
Whole Body
Type of Injury
*
Burn
Dislocation
Inflamation
Loss of Hearing
Dizzy/Feint
Mental Disorder
Foreign Body
Strain
Electric Shock
No Physical Injury
Rapture
Fracture
Laceration
Crushing
Multiple Injuries Including Both Physical and Psychological
Freezing
Asphyxiation
Hernia
Sprain
Chest Pain
Stroke
Carpal Tunnel Syndrome
Bruise
Graze
Unknown
Head Injury
None
Asthma Attack
Cardiac Arrest
Other:
Nature of Injury
*
Your answer
Was First Aid given?
*
Yes
No
Was the injured party taken from site of the accident to hospital?
*
Yes
No
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