Fillable Printable 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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