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
Your answer
Your relationship to injured athlete *
Your answer
If you're a medical professional, let us know what type
Your answer
Date of injury *
YYYY / MM / DD (e.g. 2015/09/12)
Your answer
Age of injured athlete *
Your answer
Gender of injured athlete *
Type of Program *
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
Your answer
State in which program is located *
Please spell out the state name
Your answer
Was the injured athlete wearing goggles? *
If injured athlete was wearing goggles, do you feel the goggles contributed to the severity of this injury? *
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
If another athlete was directly involved, was that athlete wearing goggles? *
If another athlete was directly involved, was the other athlete a teammate or opponent? *
If another athlete was directly involved, was the other athlete's gender the same as the injured athlete? *
Type of activity injury occured during *
Description of how injury happened and treatment required *
Your answer
Body Part Injured *
Check all that apply to this injury incident
Required
Type of Injury *
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.
Severity of Injury *
ADDITIONAL HELPFUL INFORMATION
Action injury occured during
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
Competition Surface
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.
Your area code and phone number
Your answer
Your email address *
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
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.