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Injury Report Form
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Date of Injury
MM
/
DD
/
YYYY
Time of Injury
Time
:
AM
PM
Name of Participant
Your answer
Participant Student/Wellness Center ID Number
Your answer
Classification
CU Denver Student
Community Member
Other
Clear selection
Activity
Intramural Sports
Club Sports
Other
Clear selection
Location of Injury
Court 1
Court 2
Court 3
1st floor weight room
Pool
CU Denver Field
Clear selection
Part of Body Injured
Your answer
Description of Injury
Your answer
Name of person providing 1st aid
Your answer
Treatment
Band-Aid
Ice
None
Other
Clear selection
Police Notified
Yes
No
Clear selection
Participant sent to
Home
Student Health Center
Urgent Care
Hospital
Other
Clear selection
Transportation
Private Vehicle
Ambulance
Other:
Clear selection
Was Treatment refused?
Yes
No
Clear selection
Was EMS Service Refused?
Yes
No
Clear selection
Witness Name & Student or Wellness Center ID
Your answer
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