CRMS Accident/Injury Report
Coaches, please complete this form if a student injury leads to one of these outcomes:
-You withdrew an athlete from the entirety of a game/practice after the injury occurred
-You called a parent to inform them of an injury
-You called 911 or you advised medical treatment for a student
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* Required
Name of Person Filing Report
*
Your answer
Name of Injured Person
First Name
*
Your answer
Last Name
*
Your answer
Grade
*
5
6
7
8
Other:
School
*
Camden Rockport Middle School
Other:
Time and Place of Accident/Injury
Date
*
MM
/
DD
/
YYYY
Time
*
Time
:
AM
PM
Location
*
Please be specific as to the building and location.
Your answer
Type of Accident/Injury
*
Check any that apply. If OTHER, please specify.
Sprain/Strain
Cut/Laceration
Head Injury
Lip/Mouth
Eye
Abrasion
Sting (Insect)
Puncture
Fracture
Dislocation
Burn
Bite
Required
Affected Side
Left
Right
Part of the Body
*
Ankle
Arm
Back
Chest
Collar Bone
Elbow
Eye
Face
Finger
Foot
Hand
Head
Hip
Knee
Leg
Lip
Mouth
Neck
Nose
Shoulder
Stomach
Tooth
Wrist
Other:
Required
Cause of Accident/Injury
Description of how the accident/injury occurred.
*
Your answer
Did teacher/staff member/coach witness incident?
*
Yes
No
Name(s) of witness(es):
Your answer
Action Taken
Give specific details for any that apply.
First Aid
*
Your answer
Transported by:
*
Parent/Guardian/Other Adult
Ambulance
Student transported him/herself
Required
Transported to:
*
Home
Physician
Hospital
Required
Notes
Your answer
Notifications
Parent/Guardian at event?
*
Yes
No
Date Parent/Guardian was notified
MM
/
DD
/
YYYY
Time Parent/Guardian was notified
Time
:
AM
PM
Who notified the Parent/Guardian or "other"?
*
Coach
Other:
Thank You
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