Fillable Printable Injury Report Sample Form

Injury Report Sample Form

PRIDE • PERFORMANCE • POSITIVE COACHING

1. Date of Accident ________________________________ Time _______________________

2. Name of Injured Person __________________________ Date of Birth__________________

Address _____________________________________________________________________

Phone Number_______________ Parent/Guardian Name ______________________________

Phone Number _______________Parent/Guardian Name ______________________________

3. Location of Accident

____________________________________________________________________________

4. Describe how the person was injured

____________________________________________________________________________

________________________________________________

5. Noticeable Injuries (check all that apply)

[ ] Cut [ ] Bruise [ ] Thigh [ ] Knee [ ] Lower Leg

[ ] Ankle [ ] Foot [ ] Hip [ ] Abdomen [ ] Chest

[ ] Back [ ] Neck [ ] Shoulder [ ] Arm [ ] Wrist

[ ] Hand [ ] Thumb [ ] Finger [ ] Head [ ] Face

[ ] Eye [ ] Nose [ ] Mouth [ ] Teeth [ ] Other

PBG PREDATORS

COMPETITIVE SOCCER

INJURY REPORT FORM

PRIDE • PERFORMANCE • POSITIVE COACHING

6. Medical Aid Rendered: None Needed [ ] Called 911 [ ]

First aid given [ ] – Describe

___________________________________________________________________________

Taken to Hospital – By Whom ___________________________________________________

Hospital _____________________________________________________________________

7. If injured person is under 18 years of age was a parent or legal guardian notified?

Yes [ ] In Person [ ] Phone [ ] No [ ]

8. Injured Person Released Self To Parent To other party name _________________________

9. Describe condition of injured person at time of release

____________________________________________________________________________

10. Name (s) of witness (es) at time of accident

Name ________________________________ Phone ____________________

11. Name of person completing report ______________________________________

Date ____________________

1. All injuries, including blows to the head, should be attended to by a medical professional

immediately.

2. An Accident Report Form should be completed any time there is an injury or accident.

3. The Accident Report form is to be completed only by PBG Coaching staff and Team

Managers

4. If you or someone else has additional comments, please put those on a separate paper and

attach to the Accident Report Form.

CLUB USE:

Player Released to return back to play: Yes [ ] Date ___________________________

DOC Signature: ___________________________