IR Academy Incident Reporting Form
Type of Incident (injury, referee, coaching, safety, etc)
Details of person injured or involved (to be completed and submitted by Head Coach)
Person Completing Report: *
Your answer
Date: *
MM
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DD
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YYYY
Cell Phone Number: *
Your answer
Email Address: *
Your answer
Person (s) Involved: *
Your answer
Team/Age Group *
Your answer
Incident Details
Date of Incident: *
MM
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DD
/
YYYY
Location of Incident: *
Your answer
Time of Incident: *
Time
:
Witnesses:
Your answer
Description of Event (Describe tasks being performed and sequence of events) : *
Your answer
To be Completed if an Injury was sustained
Type of injury sustained:
Your answer
First aid? Actions taken (ice, 911, bandage, transport to medical facility, etc)
Your answer
Were parents contacted or present when injury occurred? Provide name (s) date and time of contact
Your answer
DOC Information
Which DOC is being contacted? *
Your answer
Date: *
MM
/
DD
/
YYYY
Time: *
Time
:
Incidents must be reported within 24 hours verbally and written documentation within 48 hours.
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