Saint Mary's College High School - Injury Report
Please fill out all the required fields and as much additional information as possible.
Injured Person Gender *
Required
Is He/She *
Required
Injured Persons Last Name *
Your answer
Injured Person's First Name *
Your answer
Injured Person'd Date of Birth *
MM
/
DD
/
YYYY
Injured Person's Phone Number *
Your answer
Date of Injury *
MM
/
DD
/
YYYY
Time of Injury *
Time
:
Where did the Injury Occur? *
Your answer
Summary of Incident *
Your answer
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
Your answer
Body Part(s) Injured
Type of Injury (Estimation)
Disposition of Injured Person - Transported to
Transported By
Was Someone Notified or Contacted About this Injury
Who was Notified
Your answer
Name of Person Submitting this Form *
Your answer
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