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.
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Your Name
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First and Last Name
Your answer
Your relationship to injured athlete
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Your answer
If you're a medical professional, let us know what type
Your answer
Date of injury
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YYYY / MM / DD (e.g. 2015/09/12)
Your answer
Age of injured athlete
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Your answer
Gender of injured athlete
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Female
Male
Type of Program
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Township Recreation
School/College
Club
Other:
FULL name of Club/College/Recreation Department/School
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If injury happened during a school practice/game, identify school. If at a club practice/game, identify club
Your answer
State in which program is located
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Please spell out the state name
Your answer
Was the injured athlete wearing goggles?
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Yes - Polycarbonate Lens Design
Yes - Wire/Cage Design
Yes - But I don't know what kind
No
Not sure
If injured athlete was wearing goggles, do you feel the goggles contributed to the severity of this injury?
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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
If another athlete was directly involved, were they hurt?
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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
If another athlete was directly involved, was that athlete wearing goggles?
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There was no other athlete directly involved in the injury
Yes - Polycarbonate Lens Design
Yes - Wire/Cage Design
Yes - But I don't know what kind
No
Not sure
If another athlete was directly involved, was the other athlete a teammate or opponent?
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There was no other athlete directly invovled in the injury
Teammate
Opponent
Do not know
If another athlete was directly involved, was the other athlete's gender the same as the injured athlete?
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There was no other athlete directly invovled in the injury
Same gender
Diffrent gender
Do not know
Type of activity injury occured during
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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:
Description of how injury happened and treatment required
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Your answer
Body Part Injured
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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:
Required
Type of Injury
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Abrasion
Concussion
Contusion/Bruise
Fracture
Laceration
Sprain/Strain
Other:
Do you have photo(s) of the injury?
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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.
Yes
No
Severity of Injury
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Death
Permanent disability
Requires more than six weeks recovery before returning to play
Requires about six weeks recovery before returning to play
Requires two to four weeks recovery before returning to play
Requires about two weeks recovery before returning to play
Requires about one week recovery before returning to play
Requires a few days recovery before returning to play
Requires one day recovery before returning to play
Return to play same day
Other:
ADDITIONAL HELPFUL INFORMATION
Action injury occured during
Open field play (the injured athlete was attacking)
Open field play (the injured athlete was defending)
Set play - free hit/side-in/long hit (attacking)
Set play - free hit/side-in/long hit (defending)
Set play - penalty corner (attacking)
Set play - penalty corner (defending)
Set play - penalty stroke (attacking)
Set play - penalty stroke (defending)
Team area/spectating
Do not know
Other:
Clear selection
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
Clear selection
Competition Surface
Grass - Dry, blades less than 1.5" high, smooth surface
Grass - Dry, blades more than 1.5" high, smooth surface
Grass - Dry, blades less than 1.5" high, rough surface (lots of bare spots, bumps, etc)
Grass - Dry, blades more than 1.5" high, rough surface
Grass - Wet, blades less than 1.5" high, smooth surface
Grass - Wet, blades more than 1.5" high, smooth surface
Grass - Wet, blades less than 1.5" high, rough surface
Grass - Wet, blades more than 1.5" high, rough surface
Turf, Rubber Filled - Dry
Turf, Rubber Filled - Wet
Turf, No Fill - Dry
Turf, No Fill - Wet
Do not know
Clear selection
May we contact you for more information about this injury?
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We will also contact you if you clicked "Yes" you have one or more photographs of the injury.
Yes
No
Your area code and phone number
Your answer
Your email address
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Submissions will be verified via email. Be sure to enter your email address accurately.
Your answer
Additional comments if any
Please tell us how you learned about GoggleInjury.com
Your answer
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