Club Sport Injury Report Form
The Club Sport Injury Report is to be submitted anytime a member of a club sport is injured. Reports should be submitted as quickly as possible. They are due no later than 9:00am Monday morning or 24 hours following the incident, which ever is sooner.
Name of person filing report *
Your answer
Club Sport Name *
Name of Injured *
Your answer
College ID #
Your answer
Classification of Injured *
Gender *
Phone Number
Your answer
Accident Date *
MM
/
DD
/
YYYY
Time
:
Accident Location *
Cause of Accident *
Check all that apply
Required
Type of Injury *
Check all that apply
Required
Body part injured *
Check all that apply
Required
Blood Exposure *
If yes, list the name & phone number for everyone exposed:
Your answer
Emergency Care Provided *
Check all that apply
Required
Was an ambulance recommended? *
If ambulance was recommended, did the injured party refuse?
Further Care *
Required
Name of hospital or urgent care clinic
(If hospital was visited)
Your answer
Is the injured player concussed; or, do they need to visit the hospital with an injury requiring that they be checked-in on at the hospital or upon return to campus? *
If yes, have you contacted a student activities staff member?
Contact the Assistant Director of Student Activities (number provided in training) with the following information: player name, phone number, injury description, name of hospital visited (if applicable). If unavailable, contact the Director of Student Activities (number provided in training).
Signature *
By typing your full name below you atest that the above information is accurate and true to the best of your knowledge.
Your answer
Comments / Additional information
Your answer
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