SMC Club Sport Accident/Incident Report

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form is to report the incidents & accidents that occur during Club Sport practices, competitions, or other related events. There are different steps to be taken based on various situations. See below.

For Life Threatening Emergencies:

Step 1: Call Campus Safety at 925-631-4282 and notify them if EMS, Fire, or Police is needed
Step 2: Provide Emergency Care (if trained)
Step 3: Contact Club Sports Department Staff
Director of Athletic Training - Amanda Morton (707) 239-6905
Director of Recreational Sports - Jeremy Penaflor (925) 421-1309
Assistant Director of Club Sports Operations - Tom Perry (925) 389-7459
Executive Director - Rebecca Harper (925) 548-8027
Club Sport Coordinator on duty
Step 4: Fill out an Incident Report and submit it to your Sports Administrator or any Club Sports Department staff member
Step 5: Follow-Up with participant(s), coach, team, and Club Sports Administration

For Injuries:

Team Leaders are required to know and follow the emergency procedures established for Club Sports as outlined in the Club Sports Manual
Club Sports Athletes who sustain an injury will contact Director of Athletic Training - Amanda Morton.
Club Sports leaders are responsible for reporting Club Sports student-athlete injuries by using the incident report form. Club Sports leaders are also responsible for communicating updates on the injury to assigned Sports Administrator.
Off-campus injuries during competitions should be treated by medical services provided at the site or referred to the nearest emergency room. An Incident Report must be filled out and submitted to Club Sports Administration.
Club Sports leaders are responsible to call, text, or email Club Sports Administration immediately following any serious injury.

**Please refer to the Club Sport Manual for further details.**

Select Club Sport that Applies *

PART A: GENERAL INFORMATION

INVOLVED PARTY

Name (First & Last) of injured individual: *

Injured individual's SMC ID# *

Title *

Player

Staff

Coach

Other:

Injured Individual's Phone Number (xxx) xxx-xxxx *

Date Of Occurrence *

YYYY

Approximate Time Of Occurrence: *

Time

Location Of Occurrence: *

Description Of Occurrence: *

PART B: EMERGENCY RESPONSE

Campus Safety Contacted *

Yes

Emergency Medical Services Contacted? *

Yes

Other:

Responding Campus Safety Officer's Name *

First Aid Performed? *

Yes

If Yes, By Whom

What Type of Care Was Provided

After Accident/Incident, Member... *

If you answered "Other" to the previous section, please explain.

Part C: WITNESSES

Witness #1 Name (First & Last)

Phone Number (___)___-_____

Comments:

Witness #2 Name (First & Last)

Phone Number (___)___-_____

Comments:

Witness #3 Name (First & Last)

Phone Number (___)___-_____

Comments:

Part D: Report Completed By

Name (First & Last) *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Saint Mary's College of California. Report Abuse

Forms