Injury Report Form
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Santa Clara University
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Campus Recreation
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Injury Report Form
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Please Print Clearly and Legibly
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Name(of injured)Date of Injury
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AddressTime of Injury
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Phone NumberID Number
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Gender:Status:StudentMalley MemberGuest
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Faculty/StaffOther(specify)
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Type of Injury(check all that apply):
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CutFractureSprain
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DisslocationRecurring InjuryOther(specify)
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Body Part Injured(i.e. right arm, left ankle):
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Facility Where Injury Occured(check one):
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Bellomy FieldMalley PoolWeight Room
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GymnasiumMultipurpose RoomOther(specify)
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Locker RoomTennis Center
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Program and Activity during which Injury Occurred:
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Competitive Club Sports (specify sport)
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Informal Recration (specify activity)
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Intramural Sports (specify sport)
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Lifetime Recreation (specify class)
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Other(specify)
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Description of How Injury Occurred:
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What Care was Provided and What Action was Taken?(i.e. ice, bandage, ect.)ice
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Name of First Aid Provider:
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Was Campus Safety Notified?yesno
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If yes, Name of Officer Responding
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Did Paramedics/Ambulence Respond?yesno
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Was the Injured Individual Advised to Seek Medical Treatment?yesno
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Was the Injured Individual Advised to Discontinue Participation?yesno
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Did the Injured Individual Continue to Participate?yesno
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How did the Injured Individual Leave the Facility?AmbulenceFriends
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Campus SafetySelfOther(specify)
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Signature of Injured:Date:
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Signature of Person Filling Report:
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Printed Name of Person Filling Report:
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If Available, Witness Name:Phone:
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CampusRec/Emergency Response/Injury Report Form
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