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VanU Serious Injury Form
It is expected that a team official will complete this form for all injuries that involve a player being removed from a game due to an injury that sees them unable to return to play that game.
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* Indicates required question
Email
*
Your email
Name of person reporting the injury
*
Your answer
Date of incident
*
MM
/
DD
/
YYYY
Location of incident (field and city)
*
Your answer
Field surface where injury occurred
*
Choose
Artificial Turf
Grass
Gravel
Team coach's name
*
Your answer
Player's name
*
Your answer
Age group
*
U4-5
U6-8
U9-10
U11-12
U13
U14
U15
U16
U17
U18
Required
Level of play
*
House (U4 to U10)
Div 1
Div 2
Div 3
Metro
BCSPL
Description of incident and injury if known
*
Your answer
Action taken at the field (eg. player removed from game, ice applied)
*
Your answer
Protocol checklist: At field (please select all that were done)
*
Assessed injury
Called 911
Player's parents notified
Team First Aid kit used
Other:
Required
Protocol checklist: Post game (please select all that were done)
*
Player taken to hospital
Player consulted a medical specialist (not at hospital)
Concussion guidelines provided to parents (for head injuries)
Return to Play Guidelines provided to parents
Other:
Required
Return to Play Protocol
*
Player has been assessed by a medical specialist
Player has provided doctor's note confirming they are fit to play
For concussions: all concussion protocols have been followed and completed
Required
Date of Return to Play (as recommended by medical specialist)
*
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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