Saint Mary's College High School - Injury Report
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Injured Person Gender *
Required
Is He/She *
Required
Injured Persons Last Name *
Injured Person's First Name *
Injured Person'd Date of Birth *
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/
DD
/
YYYY
Injured Person's Phone Number *
Date of Injury *
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/
DD
/
YYYY
Time of Injury *
Time
:
Where did the Injury Occur? *
Summary of Incident *
Possible Worker's Compensation Injury? *
Required
For Inter-School Sports, Select a Sport
If Injury Occurred During a Sporting Event, Was it a
If Injury Occurred Other Than at a Sporting event Indicate from the Following
If Other, Indicate Where
Body Part(s) Injured
Type of Injury (Estimation)
Disposition of Injured Person - Transported to
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Transported By
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Was Someone Notified or Contacted About this Injury
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Who was Notified
Name of Person Submitting this Form *
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This form was created inside of Saint Mary's College High School.