Injury Incident Report Form
Please fill out this form on-site at the time of an observed/reported injury
Date
MM
/
DD
/
YYYY
Session
Player Name:
Your answer
Player E-mail or Cell:
Your answer
Witnessed by:
Your answer
Reported by:
Your answer
Location of incident (Court #, Hallway, Bathroom, etc.):
Your answer
Describe the incident in detail including precipitating factors:
Your answer
Risk Level or Severity
Describe the action taken:
Your answer
Outcome:
Your answer
Board Members:
Your answer
Follow-up comments from Board Member(s):
Your answer
Submit
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