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Incident Report
Athletic Injury Report Form
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* Indicates required question
Name of Injured:
*
Your answer
Address of Injured
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Parent Name:
*
Your answer
Parent Email
*
Your answer
Parent phone number:
*
Your answer
Date of Injury:
*
MM
/
DD
/
YYYY
Time of Injury
*
Time
:
AM
PM
Circumstance of Injury
*
Your answer
Was this injury a concussion or suspected concussion?
*
Yes
No
Injury Location
*
School Building
School Grounds
School Bus
To or From School
Away Athletic Event
Other:
Injury Location
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Classroom
Hallway
Field
Gym
Off site
Other:
Nature of How Injury Occurred
*
Single individual Injury
Contact With Another Player
Head to Floor Contact
Head to Turf Contact
Other:
Witness/Coach Name:
*
Your answer
Contact info for Witness/Coach
*
Your answer
Was medical treatment sought?
*
Yes
No
Other:
Was an ambulance called?
*
Yes
No
Other:
Additional Comments -
*
Your answer
Person Reporting Incident:
*
Your answer
Title of Person Reporting Incident:
*
Your answer
Today's Date:
*
MM
/
DD
/
YYYY
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