AcroYoga Injury Survey
Thanks for taking the time to fill out a report. We may publish some of these injury accounts as a learning resource for the AcroYoga community and to gather data from the collection of many accounts.

The first section asks for the basic information. Please fill all of this out. If you are willing, we'd also like to have more detailed information. Full narratives, analysis, and suggestions for others are greatly appreciated.

The person filling out this form should be familiar with the circumstances of the injury - either the person(s) involved or a rescuer involved in the incident. Please provide contact information so we can follow up with questions.

Reports submitted here will be used for safety analysis, compilation of data to identify common occurrences, and may be published in part or in full. If you would prefer your report is not published, please check the box at the end.
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Name
(Names will not be publicly shared without permission and are for internal contact purposes only.)
E-mail
(For internal contact purposes only, if we have any questions about your report.)
Your role
(Were you the person injured? Base, flyer, spotter, observer? )
Location
Date
(Feel free to report old incidents. If exact date is unknown, select an approximate date.)
MM
/
DD
/
YYYY
Type of event
Clear selection
Host of event
(ex. AcroYoga.org, AcroRevolution, studio name, none)
Teacher(s)
(If the incident occurred at a structured class or workshop, who was teaching the event?)
Type of activity
Type of injury
(You may check more than one)
Was hospitalization required?
Clear selection
Narrative Description of Injury *
(Use as much space as needed to tell the complete story of the injury. Please be specific and include events that led to injury, skill level, experience and training specific to what was being attempted, any contributing factors such as fatigue, alcohol , etc.)
Narrative Description of Recovery
(Is the injured person fully recovered? If yes, how long did recovery take? If not, what is the current state of health during recovery? Has the injury required physical therapy? Surgery? Other treatment?)
Can we publish this report? *
(Names and personal details can be removed and you will be contacted before publishing.)
Detailed Information
Full narratives, analysis, and suggestions for others are greatly appreciated.
Persons Involved (and Ages, Experience Level)
(Use full name or a number [ex., “Person 1”]. Provide ages and experience levels of persons directly involved.)
Keep Participant Names Anonymous
(Would you prefer to keep person's names involved in the accident anonymous?)
Clear selection
Experience Level of Reporter
(Please let us know how you view your own skill level.)
Clear selection
Experience Level of Injured Person
(What is the skill level of the person injured?)
Clear selection
Causes and contributing factors
(What caused this incident, to the best of your knowledge)
Was the incident photographed/recorded?
Clear selection
Analysis
(Provide your own analysis of what went wrong. What knowledge and techniques might help prevent similar injuries in the future?)
Links to additional information
Comments
(Please use this space for any final comments.)
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