CMRLL Incident - Injury Report Form
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. For all claims or injuries which could become claims, please fill out and turn in the official Little League Baseball Accident Notification Form available from your league president and send to Little League Headquarters in Williamsport (Attention: Dan Kirby, Risk Management Department). Also, provide your District Safety Officer with a copy for District files. All personal injuries should be reported to Williamsport as soon as possible.
Incident Date *
Insert the date of the incident - injury
MM
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DD
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YYYY
Incident Time *
Insert the start time of the incident - injury
Time
:
Field Name - Location *
Your answer
Injured Person's & Parent's Name *
Your answer
Injured Person's & Parent's Address *
If Injured person's name is different from parent's address, please list both addresses.
Your answer
Male or Female *
Injured Person's Date of Birth *
MM
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DD
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YYYY
Injured Person & Parent Home & Work Phone Number *
Example: XXX-XXX-XXXX
Your answer
In which division did this injury occur? *
Injury occurred while participating in the following activity. *
Position/Role of person(s) involved in incident: *
Required
Explanation of Incident - Injury *
Your answer
Was First Aid Required? *
If Yes, please provide details of treatment applied.
Your answer
Was professional medical treatment required? *
If yes, please provide details of professional medical treatment. (If yes, the player must present a non-restrictive medical release prior to to being allowed in a game or practice.)
Your answer
Type of Incident and Location *
Required
Please give a short description of incident: *
Please be detailed in our description.
Your answer
Could this accident have been avoided? *
Please explain how it could've been avoided
Your answer
Prepared By *
Name of person submitting injury - incident report.
Your answer
*
Date and time submitted
MM
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DD
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YYYY
Time
:
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