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
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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