Club Sports Injury/Accident Report Form
General Information
Name of Person Submitting Report
Your answer
Email of Person Submitting Report
Your answer
Phone Number of Person Submitting Report
Your answer
Date of Injury/Accident
MM
/
DD
/
YYYY
Time
:
Location (Alumni Gym, Sachem Fields, etc)
Your answer
Club Sport
Your answer
Injured Person's Information
Injured Person's Name
Your answer
Address
Your answer
Phone Number
Your answer
Affiliation of Injured Person (Dartmouth student, non-Dartmouth student, etc)
Your answer
Date of Birth
MM
/
DD
/
YYYY
Dartmouth NetID
Your answer
Gender
Your answer
Witness/Reporting Safety Officer
Witness Name
Your answer
Witness Phone Number
Your answer
Injury Information
Suspected Type of Injury (check all that apply)
Required
Side of Body Injured
Required
Location of Injury
Required
Details of the Injury/Accident
Please describe how the injury/accident occurred in detail. Include any involvement with equipment, facility, weather or field issues.
Your answer
What was the immediate action taken to treat the injury?
Your answer
Was Safety & Security Called
Was 911 Called?
First Aid Administered By?
Your answer
Any additional comments or information?
Your answer
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