Injury/Incident Report

Please complete this form regarding any injury/incident.
Name
Name of Player or Subject(s) of the Incident
Team Name
Name of Team Involved
Head Coach Name
Name of Head Coach
Program Type
select
Football or Cheerleading
Incident Type
select
Incident Type
Injury/Incident Date
RadDatePicker
RadDatePicker
Open the calendar popup.
Actual Date of Injury/Incident
Incident/Injury Time
Time of injury/incident
Reported to Whom
select
Who was the Injury/Incident Reported to?
Location
select
If injury/incident occured outside the locations listed, select other and detail it in your description
Witnesses
Who witnessed the incident/injury?
Setting
select
If the injury/incident occured outside of practice or a game, select other and detail it in your summary.
Injury Time Out
select
Was an injury time out called by the official?
Player Age Level
select
What age level?
Description
Brief Description of Injury/Incident
Reporting Party
Who is reporting this injury/incident?
Removed
select
In case of injury, was the athlete removed from practice or competition?
Police Contacted
select
Was law enforcement contacted?
Ambulance Called
select
Was EMS contacted?
Sent for Medical
select
Were the parent/guardian instructed to seek medical attention?
Parent Notification
select
Was the parent/guardian notified?
Medical Clearance
select
Were the parents/guardian instructed to provide medical clearance before the athlete can resume participation?
Concussion-Return
select
In the event of a concussion, was the return to play process explained to the parents/guardian?
Insurance Claim Form
select
Were the parents directed to the team website for insurance forms?
PSD Notification
select
Was Player Safety Director Mike Gojcaj notified?
Pres. Notification
select
Was Team President Brian Baker notified?
Additional Comments
Additional Comments
Date Submitted
RadDatePicker
RadDatePicker
Open the calendar popup.
Report Submission Date
Required Fields