Injury Report Form
This form should be filled out immediately following any incident at an ACA-sanctioned activity that meets at least one of the following criteria:

* Referral to a medical provider beyond onsite first aid or EMS
* Unable to train / compete beyond day of injury
* Miss school or work

Completing this form is required regardless of whether or not you intend to file a claim with the ACA's insurance provider. This ensures that if an injury results in further care beyond the initial assessment the report is complete to accompany a potential future claim.

IMPORTANT: Information regarding the ACA's insurance and instructions for filing an Excess Accident Medical claim can be found here: https://drive.google.com/file/d/1AteU1aI34mZC3iTNFfAdwzgiO9eQ7PZl/view?usp=sharing
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Email *
Name of person filing report: *
Phone number of person filing report: *
Team (enter N/A if not affiliated with a team): *
Which of the following is the injured person? *
Name of injured person: *
Sex of injured person: *
Date of birth of injured person: *
MM
/
DD
/
YYYY
If injured person is a minor, name of parent / guardian: *
If injured person is a minor, phone number of parent / guardian: *
Address of injured person: *
Date of incident: *
MM
/
DD
/
YYYY
Time of incident: *
Time
:
Location of incident: *
During which activity did incident occur? *
Affected body part (check all that apply): *
Required
Describe the injury: *
Describe the circumstances that caused the injury: *
What onsite care was provided (check all that apply)? *
Required
Was the parent / guardian notified? *
Which of the following results from the injury (check all that apply)? *
Required
Was the injured person able to complete the practice or race?
Clear selection
Was the injured person evacuated by emergency personnel?
Clear selection
Did the injured person go to the hospital at any time for the injury?
Clear selection
Name of person leading ride or event when incident occurred:
Witness #1 name: *
Witness #1 email address: *
Witness #1 phone number: *
Witness #2 name: *
Witness #2 email: *
Witness #2 phone number: *
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