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