Simsbury Little League Injury Reporting Tool
This form is for Little League purposes only, to report safety hazards, unsafe practices and/or to contribute positive ideas in order to improve league safety. When an accident occurs, obtain as much information as possible. 
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What field did the injury occur? *
What was the DATE of the incident? *
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What was the TIME of the incident? *
Time
:
What is the injured person's NAME? *
What is the injured person's AGE?  *
What is injured person's SEX? *
What is the name of the parent (if applicable) of the injured person? *
The injury occurred during:  *
What is the players division?  *
What team does the player participate on? 

If the injury was not to a player, please use N/A.
 *
Event Type? *
What was the position or role of the injured player? *
Required
Type of injury: *
Was first aid required?  *
Was professional medical treatment required?  
 *
If Yes, briefly describe the treatment required
Did this injury occur on the playing field?  *
Where did the incident occur?   *
What type of incident occurred? 
Please give a short description of the incident. *
Could the accident have been avoided?  *

This form is for Little League purposes only, to report safety hazards, unsafe practices and/or to contribute positive ideas in order to improve league safety. When an accident occurs, obtain as much information as possible.

Please direct all questions to Michael Suprenant, Safety Director (mpsuprenant@gmail.com)

Prepared by:  *
Phone Number *
Email address: *
Date prepared: *
MM
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Signature:  *
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