Field Hockey Goggle Injury Report

GoggleInjury.com is the brain child of a task force of dedicated individuals from the field hockey community. The task force includes medical professionals (orthopedic surgeon, trauma surgeon, vascular surgeon, general surgeon), a doctoral student at Yale University, a board member of USA Field Hockey, a former certified athletic trainer, and multiple field hockey club owners, coaches, and umpires. GoggleInjury.com is the first and only nationally available, standard reporting mechanism that is open to the public for reporting goggle related injuries. In order to ensure accuracy and the highest reporting standard possible, please be sure to complete this form very carefully. No personal identity information will be released to the public without permission.

Your Name

First and Last Name

This is a required question

Your relationship to injured athlete

This is a required question

If you're a medical professional, let us know what type

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Date of injury

YYYY / MM / DD (e.g. 2015/09/12)

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Age of injured athlete

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Gender of injured athlete

Female
Male

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Type of Program

Township Recreation
School/College
Club
Other:

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FULL name of Club/College/Recreation Department/School

If injury happened during a school practice/game, identify school. If at a club practice/game, identify club

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State in which program is located

Please spell out the state name

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Was the injured athlete wearing goggles?

This is a required question

If injured athlete was wearing goggles, do you feel the goggles contributed to the severity of this injury?

The athlete was not wearing goggles
Goggles caused the injury
Goggles made the injury worse
Goggles reduced the severity of the injury
Goggles did not impact the severity of the injury

This is a required question

If another athlete was directly involved, were they hurt?

Injuries directly involving another athlete include those resulting from a collission, being hit by another athlete's stick, a ball rasied by the opponent or teammate

There was no other athlete directly involved in the injury
Yes
No
Do not know

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If another athlete was directly involved, was that athlete wearing goggles?

This is a required question

If another athlete was directly involved, was the other athlete a teammate or opponent?

There was no other athlete directly invovled in the injury
Teammate
Opponent
Do not know

This is a required question

If another athlete was directly involved, was the other athlete's gender the same as the injured athlete?

There was no other athlete directly invovled in the injury
Same gender
Diffrent gender
Do not know

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Type of activity injury occured during

Practice - Drills
Scrimmage -- Against ourselves
Scrimmage -- Against another school/club
Competition - Regular Season
Competition - Post Season Tournament (County, Conference, State, National, etc)
Competition - Special Event (Regional, National, International Game/Tournament)
Other:

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Description of how injury happened and treatment required

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Body Part Injured

Check all that apply to this injury incident

Head - Concussion/Skull (including orbit)
Head - Soft tissue face (eyebrow, ear, forehead, cheek, near the eye but not the eyeball, etc)
Head - The Eyeball (damage to the cornea, lens, pupil)
Below Head and above Hips
Hips and below to Knee
Below Knee
Other:

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Do you have photo(s) of the injury?

Only click YES if we may contact you for the photograph(s) and please enter your email address at the end of the form so we can contact you.

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ADDITIONAL HELPFUL INFORMATION

Legality/Danger of situation involving injury

Was the injured athlete (or another athlete directly inolved) playing dangerously or committing a foul at the time of the injury

Illegal/Dangerous Play
Legal Play
Do not know

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May we contact you for more information about this injury?

We will also contact you if you clicked "Yes" you have one or more photographs of the injury.

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Your area code and phone number

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Your email address

Submissions will be verified via email. Be sure to enter your email address accurately.

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Additional comments if any

Please tell us how you learned about GoggleInjury.com

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