Injury Report Form

	A	B	C	D	E	G	H	J	L
1	Santa Clara University
2	Campus Recreation
3	Injury Report Form
4	Please Print Clearly and Legibly
5	Name	(of injured)					Date of Injury
6	Address						Time of Injury
7
8	Phone Number					ID Number
9		Gender:			Status:	Student		Malley Member	Guest
10						Faculty/Staff		Other(specify)
11	Type of Injury		(check all that apply):
12				Cut		Fracture		Sprain
13				Disslocation		Recurring Injury		Other(specify)
14
15	Body Part Injured			(i.e. right arm, left ankle):
16
17	Facility Where Injury Occured				(check one):
18				Bellomy Field		Malley Pool		Weight Room
19				Gymnasium		Multipurpose Room		Other(specify)
20				Locker Room		Tennis Center
21
22	Program and Activity during which Injury Occurred:
23				Competitive Club Sports (specify sport)
24				Informal Recration (specify activity)
25				Intramural Sports (specify sport)
26				Lifetime Recreation (specify class)
27				Other(specify)
28
29	Description of How Injury Occurred:
30
31
32
33	What Care was Provided and What Action was Taken?						(i.e. ice, bandage, ect.)		ice
34
35
36
37	Name of First Aid Provider:
38
39	Was Campus Safety Notified?							yes	no
40	If yes, Name of Officer Responding
41	Did Paramedics/Ambulence Respond?							yes	no
42	Was the Injured Individual Advised to Seek Medical Treatment?							yes	no
43	Was the Injured Individual Advised to Discontinue Participation?							yes	no
44	Did the Injured Individual Continue to Participate?							yes	no
45	How did the Injured Individual Leave the Facility?							Ambulence	Friends
46				Campus Safety		Self		Other(specify)
47
48	Signature of Injured:							Date:
49	Signature of Person Filling Report:
50	Printed Name of Person Filling Report:
51	If Available, Witness Name:							Phone:
52								CampusRec/Emergency Response/Injury Report Form
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100