AMHL Incident and Injury Reporting Form

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This form provides a brief description of any on or off ice incidents, allowing the head trainer to document and follow-up on any potential injuries or concerns. Team trainers are to fill this form any time there is an incident that requires intervention that goes beyond minor care e.g. providing a bandaid for a small cut

Email *

Name and role of reporting individual
*

Contact information including email and phone number for reporting individual
*

Full Name of Player
*

Team and Level/Division
*

Best Contact Number for Player/Family
*

Time and Date of Incident
*

Description of Incident
*

All Initial Assessment Findings, and/or Concerns for Potential Injury

e.g. leg laceration, concussion, ?broken bone

Intervention that was taken for above injuries, or recommendations made for follow-up
*

Was EMS contacted at the time of the incident
*

Yes

Are there any symptoms or signs that are concerning for concussion, following any impact to the head, including but not limited to:
*

Loss of conciousness

Any loss of memory of events immediately before or after the incident

Dazed, disoriented, or confused

Weakness, numbness, or tingling in extremities

Headache

Nausea or Vomiting

Vision changes

Drowsiness

None

Other:

Required

If any of above symptoms concerning for concussion, have you advised the player to stop activity immediately, and seek medical assessment? (please do this if possible)
*

Yes

A copy of your responses will be emailed to the address you provided.

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