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Fillable Printable Sample Injury Report Form

Fillable Printable Sample Injury Report Form

Sample Injury Report Form

Sample Injury Report Form

AMERICAN UNIVERSITY
INTRAMURAL/CLUB SPORTS
INJURY REPORT
INJURED PERSON
Name_________________________ Local Address__________________________
AU ID_______________________ Phone
Age_______ Sex_______ Class: Fr___Soph____Jr___Sr___ Grad F/S______
INJURY
Date of Injury: _____/_____/____ Time of Injury: ____:____ (am/pm)
Place of Injury: ____________________
Nature of Suspected/Stated Injury/Illness (Please be detailed):_____________________________
______________________________________________________________________________
____________
Description of Incident (describe fully, events, actions, and conditions involved):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Witnesses Information (Name, Address, and Phone):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
IMMEDIATE ACTION TAKEN
First Aid Treatment Given: __ YES __ NO
By Name: _________________ Phone #: ______________
Describe First Aid Rendered: ______________________________________________________
Called Public Safety __YES __ NO
By Name: ____________________ Phone #:__________
Responding Officer: ____________________
Report Number: _______________________
Referred to Student Health Center? ___YES ___NO
Sent to Hospital? ___YES ___ NO
By____Ambulance _____ Personal Vehicle _____ Friends Vehicle (name) _____________
Other Action Taken: ____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
________________________________________ ______
REFUSAL OF TREATMENT:
I, ______________________________, understand that at my discretion, I can choose not to seek
medical treatment recommended by the emergency medical personnel and hereby choose to do so.
Student’s Signature: _______________________________ Date: __________________________
REFUSAL OF TRANSPORT:
I, ________________________________, understand that at my discretion I can refuse official transport
to a licensed health care facility. I understand that by signing this refusal I release American University and
its agents from all responsibility for any claim rising from this decision.
Student’s Signature: _______________________________ Date: __________________________
Form Submitted by: __________________________
Signature: _______________________________ Date: __________________________
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