Injury Report
For all head injuries and any other injury where medical treatment is likely needed
Reporter's Name (Last, First)
Your answer
Reporter's Phone Number
Your answer
Reporter's Email Address
Your answer
Date of Incident
MM
/
DD
/
YYYY
Time of Incident
Time
:
Location of Incident
Your answer
Injured Party's Name *
Your answer
Is this a Partnership Team *
Is this a head injury *
Please provide a brief description of the injury and how it happened. *
Your answer
Was 9-1-1 Called?
Did Injured party receive follow up medical care? If so please provide any additional information you have
Your answer
If this is a possible concussion please click the link below for follow-up regarding the concussion protocol.
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