"Incident / Accident Report Form - Arlington Classics Academy"

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ACA Incident / Accident Report Form
If additional space is needed, please attach a separate piece of paper.
DATE OF INCIDENT________ TIME OF INCIDENT______AM/PM
DOES THE INJURED PERSON HAVE OTHER MEDICAL
 YES
 NO
Name of Club:_______________________________
INSURANCE?
Address:____________________________________________________
If yes, please provide name of company and policy #:________________
Telephone Number:___________________________________________
____________________________________________________________
 Athlete
 Official
 Coach
INJURED PERSON:
DID THIS TAKE PLACE DURING:
 Practice
 Competition
 Club Activity/Event
 Spectator
 Employee  Volunteer
 Other ____________
 Pre-activity
 Sanctioned Activity/Event
Yes
No
Was injured person a member of organization?
 After activity
 While traveling
INJURED PERSON INFORMATION
 Single
 Married
Last Name
First
Middle
Telephone Number (
)
Address
Social Security Number (optional)
City
State
Zip
Employer and Address
 Male  Female
Age
D.O.B.
GUARDIAN/PARENT (IF INJURED PERSON IS A MINOR)
Last Name
First
Middle
Telephone Number (
)
Address
City
State
Zip
SUSPECTED PRE-EXISTING CONDITION:  Yes  No
INCIDENT LOCATION
INCIDENT
MEDICAL SERVICES
 Competition area
 Concession area
 Assault/Sexual
 Slip, bodily reaction
 Antacid
 Eye rinse
 Parking lot
 Admission area
 Assault/Non-Sexual
 Slip/Fall
 Aspirin
 Glucose
 Restrooms/locker rooms  Off property
 Fall (different level)
 Eligibility
 Aspirin substitute
 Ice Pack
 Premises/grounds
 Store area
 Fall (same level)
 Aquatic
 Bandaged
 Oxygen
 Bleachers/stands
Caught in, on, between
 Trip/Fall
 Ointment/antiseptic
 Rest
 Animal/insect bite/sting
 Drug Testing
 Removal
 Splinted
 Collision (with object)
 Overexertion
 CPR
 Wrapped
CLASSIFICATION
 Facility or event related
 Non-injury
 Collision (participant/participant)
 Cleansed
 Exam
 Not facility or event related
 Collision (participant/spectator)
 Cold Pack
 Minor injury or illness
 Collision (spectator/spectator)
 None
 Serious injury or illness
 Struck by falling/flying object
Auto/Property
Treated By: ______________________
PRIMARY INJURY
BODY PART INJURED
DISPOSITION
 Allergy
 Dislocation
 Nausea
 Eye
 Torso
 Arm (L/R)
 Released to parent
 Police
(L/R)
 Amputation
 Electrical Shock  Stroke
 Nose
 Back
 Tooth
 Refusal of care
 Ambulance
 Abrasion
 Foreign Body
 Burn
 Neck
 Face
 Head
 Refer to doctor
 Report only
 Laceration
 Fracture
 Death
 Ear
 Leg
 Refer to hospital or clinic
(L/R)
(L/R)
 Drowning
 Heat Exhaustion  Pain
 Knee (L/R)
 Ankle (L/R)
 Medical attention
 Hypertension
 Cardiac
 Illness
 Internal
 Hip
 EMS transport
(L/R)
 Cold Injury
 Contusion
 Sting/bite
 Shoulder (L/R)  Foot (L/R)
 Patient requested EMS transport
 Seizures
 Concussion
 Elbow (L/R)
 Hand (L/R)
 Released to personal vehicle
 Strain/Sprain
 Tooth/Mouth
 Wrist (L/R)
 Finger or Toe
Revised 02.02.2012
ACA Incident / Accident Report Form
If additional space is needed, please attach a separate piece of paper.
DATE OF INCIDENT________ TIME OF INCIDENT______AM/PM
DOES THE INJURED PERSON HAVE OTHER MEDICAL
 YES
 NO
Name of Club:_______________________________
INSURANCE?
Address:____________________________________________________
If yes, please provide name of company and policy #:________________
Telephone Number:___________________________________________
____________________________________________________________
 Athlete
 Official
 Coach
INJURED PERSON:
DID THIS TAKE PLACE DURING:
 Practice
 Competition
 Club Activity/Event
 Spectator
 Employee  Volunteer
 Other ____________
 Pre-activity
 Sanctioned Activity/Event
Yes
No
Was injured person a member of organization?
 After activity
 While traveling
INJURED PERSON INFORMATION
 Single
 Married
Last Name
First
Middle
Telephone Number (
)
Address
Social Security Number (optional)
City
State
Zip
Employer and Address
 Male  Female
Age
D.O.B.
GUARDIAN/PARENT (IF INJURED PERSON IS A MINOR)
Last Name
First
Middle
Telephone Number (
)
Address
City
State
Zip
SUSPECTED PRE-EXISTING CONDITION:  Yes  No
INCIDENT LOCATION
INCIDENT
MEDICAL SERVICES
 Competition area
 Concession area
 Assault/Sexual
 Slip, bodily reaction
 Antacid
 Eye rinse
 Parking lot
 Admission area
 Assault/Non-Sexual
 Slip/Fall
 Aspirin
 Glucose
 Restrooms/locker rooms  Off property
 Fall (different level)
 Eligibility
 Aspirin substitute
 Ice Pack
 Premises/grounds
 Store area
 Fall (same level)
 Aquatic
 Bandaged
 Oxygen
 Bleachers/stands
Caught in, on, between
 Trip/Fall
 Ointment/antiseptic
 Rest
 Animal/insect bite/sting
 Drug Testing
 Removal
 Splinted
 Collision (with object)
 Overexertion
 CPR
 Wrapped
CLASSIFICATION
 Facility or event related
 Non-injury
 Collision (participant/participant)
 Cleansed
 Exam
 Not facility or event related
 Collision (participant/spectator)
 Cold Pack
 Minor injury or illness
 Collision (spectator/spectator)
 None
 Serious injury or illness
 Struck by falling/flying object
Auto/Property
Treated By: ______________________
PRIMARY INJURY
BODY PART INJURED
DISPOSITION
 Allergy
 Dislocation
 Nausea
 Eye
 Torso
 Arm (L/R)
 Released to parent
 Police
(L/R)
 Amputation
 Electrical Shock  Stroke
 Nose
 Back
 Tooth
 Refusal of care
 Ambulance
 Abrasion
 Foreign Body
 Burn
 Neck
 Face
 Head
 Refer to doctor
 Report only
 Laceration
 Fracture
 Death
 Ear
 Leg
 Refer to hospital or clinic
(L/R)
(L/R)
 Drowning
 Heat Exhaustion  Pain
 Knee (L/R)
 Ankle (L/R)
 Medical attention
 Hypertension
 Cardiac
 Illness
 Internal
 Hip
 EMS transport
(L/R)
 Cold Injury
 Contusion
 Sting/bite
 Shoulder (L/R)  Foot (L/R)
 Patient requested EMS transport
 Seizures
 Concussion
 Elbow (L/R)
 Hand (L/R)
 Released to personal vehicle
 Strain/Sprain
 Tooth/Mouth
 Wrist (L/R)
 Finger or Toe
Revised 02.02.2012
Describe how the incident occurred:
WITNESS INFORMATION
NAME
ADDRESS
TELEPHONE NUMBER
1.
(
)
2.
(
)
3.
(
)
4.
(
)
5.
(
)
Signature of Official (with no relationship to claimant) ________________________________________________________________
Date: ___________ Phone # _____________
Send Completed Report to:
ACA
503 Sophia St. Suite 100
Fredericksburg, VA 22401
Email: aca@americancanoe.org
Phone: (540) 907-4460
Fax: (888) 229-3792
Activity organizers, trip leaders and trip coordinators must report all injuries requiring medical attention to the ACA
National Office within seven (7) days using the ACA Incident / Accident Report Form. The report form must be
accompanied by the original waiver of the injured party. In the event of a serious injury, immediately notify the
insurance company (American Specialty) by calling 1-800-245-2744. American Specialty will answer calls to this
number 24 hours a day, 365 days a year (if calling after hours, follow the instructions for emergency claims reporting).
Revised 02.02.2012
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