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 complete this form any time there is an incident that requires intervention that goes beyond minor care e.g. providing a band-aid for a small cut.

Email *

Name and role of reporting individual
*

Contact information including email and phone number of the reporting individual.
*

Players full name *

Level, age division, team name. *

Player phone number and email. *

Date and time of incident.
*

Location of incident (rink name).

Description of Incident
*

Injuries found or concerns for potential injury.

(eg, leg laceration, possible concussion....)

What interventions and/or recommendations were done for the above injuries/concerns?
*

Any signs or symptoms that may cause concern for a possible concussion? *

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 the above concussion symptoms were present, was the player removed from play? *

Yes

Were the player and/or their guardians advised to seek medical attention if concussion symptoms were present?

Yes

Clear selection

Were Paramedics contacted at the time of the incident?
*

Yes

Who assumed care of the player?

(name, phone number, email)

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

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