SSB Accident Report
IMPORTANT: This is a legal document. Carefully completing all relevant sections on the front and back of this form, pro-viding as much information as possible. Submit completed form to the SSB Staff within 24 hours.
For emergencies requiring transport, call a SSB Organizer on duty as soon as possible after Accident Report completed.
Email address
INDIVIDUAL FILLING OUT REPORT
Job Title
Your answer
Date & Time
MM
/
DD
/
YYYY
Time
:
Police Notified?
Officer Name & Badge #
Your answer
INJURED PARTY PERSONAL DATA
First Name
Your answer
Last Name
Your answer
SSB Team
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Phone Number
Your answer
Date of Birth
MM
/
DD
/
YYYY
Gender
ACCIDENT WITNESSES
1. First & Last Name as well as phone number
Name and phone number
Your answer
2. First & Last Name as well as phone number
Name and phone number
Your answer
DETAILS OF ACCIDENT
Date & Time of Accident
MM
/
DD
/
YYYY
Time
:
Sport/Activity
Required
Where did injury occur?
What is the park or school name that the accident occurred?
Your answer
PART OF BODY INJURED
Check all that apply
Required
HOW DID INJURY OCCUR
(specify events leading to the accident/injury)
Check all the apply:
Required
DESCRIBE IN DETAIL EXACTLY HOW THE INJURY OCCURRED (as observed or as reported to you by the participant)
Your answer
COMMENTS MADE BY INJURED PARTICIPANT (with regard to how the injured part feels, what hurts, any complaints)
Your answer
SUSPECTED CLASSIFICATION OF INJURY
Check all that apply
Required
Does the participant have a history of injury/surgery that may have contributed to this injury?
FIRST AID ADMINISTERED BY
Name & Phone
Your answer
ACTION TAKEN:
Required
DESCRIBE IN GREATER DETAIL
Your answer
EMERGENCY RESPONSE AND CONTACT INFORMATION
ADDITIONAL ASSISTANCE SUMMONED?
Exact time of call made to EMS
Time
:
Exact time of arrival of EMS
Time
:
Ambulance #/Name of Company responding
Your answer
Name & # of person (parent, friend, spouse) to be notified if transported to hospital:
Contact this person immediately after participant has been transported
Your answer
SSB Staff Member call to emergency contact:
*CONTACT THIS PERSON IMMEDIATELY AFTER PARTICIPANT HAS BEEN TRANSPORTED.
Your answer
Time:
Time
:
SIGNATURE OF INJURED PARTICIPANT
I agree that the information reported on this form is accurate and true.
Signature of Injured Participant (or parent of minor dependent)
Your answer
Date:
MM
/
DD
/
YYYY
SUBSEQUENT ACTION TAKEN
Required
Driven To:
Your answer
Hospital By:
Your answer
BLOODBORNE PATHOGEN EXPOSURE CONTROL
Blood or potentially infectious materials present?
Personal protective equipment (gloves) worn?
If no, did an Exposure Incident occur?
Biohazardous waste created?
Disposed of properly in BHW container?
Specify what was disposed of and where (e.g. gloves, bandages in BHW container):
Your answer
Did participant leave the facility/field before contaminated items could be collected for proper disposal?
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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