Injury Report Form

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INJURY REPORT FORM
PLEASE PRINT
Accident Date: ____/____/____
Time: ________ am/pm
Sex: M ___ F ___
Name of Injured: ______________________________ Phone: ___________________ I.D. # _________________________
Permanent Address: ______________________________________________________________________________________
Name of Area Supervisor: _________________________________________________________________________________
1. CLASSIFICATION OF INJURED (check one)
Student
Faculty/Staff
Member
Guest
Employee
2. IS THE INJURED A MINOR?
___ Yes ___ No
3. ACCIDENT LOCATION (check one)
Recreation Center
Outdoors
Other (specify)
4. ACTIVITY AREA OF ACCIDENT (check one)
Aerobics Room
Locker Room
Weight Room
Fitness Area
Pool
Outdoor Tennis
Rec Fields, __________
Gym
Racquetball Court
Track
Other (specify)
5. PROGRAMMER (check one)
Personal Fitness
Informal Recreation
Instructional Programs
Rec Sports
Sports Club
Other (specify)
6. ACTIVITY AT TIME OF ACCIDENT (check one)
Aerobics
Football
Softball
Weight Training
Basketball
Racquetball
Swimming
Other (specify)
Diving
Soccer
Volleyball
7. CAUSE OF ACCIDENT (check one)
Collision with obstacle (wall, post, etc)
Hit by striking implement (racquet, etc)
Collision with person
Previous Injury
Fall
Sudden turn, twist, or stop
Hit by projectile (ball, bat, etc)
Other (specify)
8. TYPE OF INJURY SUSPECTED IF KNOWN (check any that apply)
Bruise
Dislocation
Laceration
Other (specify)
Concussion
Fracture
Sprain/Strain
9. BODY PART INJURED (note side of injury using “R” for right side and “L” for left side)
___ Abdomen
___ Face
___ Head
___ Shoulder
___ Up. Leg
___ Ankle
___ Fingers
___ Knee
___ Thumb
___ Wrist
___ Back
___ Foot
___ L. Arm
___ Toes
___ Elbow
___ Hand
___ L. Leg
___ Trunk
___ Eyes
___ Hip
___ Neck
___ Up. Arm
10. BLOOD EXPOSURE (check one)
_____ Yes
_____ No
Name/Phone: ________________________
11. FIRST AID RENDERED (check all that apply)
CPR/Rescue Breathing
Stopped bleeding
None rendered
Gave Ice
Washed wound
Other (specify)
Kept immobile
Victim of self-care
12a. WAS AN AMBULANCE RECOMMENDED TO BE CALLED?
___ Yes
___ No
12b. IF YES TO 12a, DID THE VICTIM REFUSE AMBULANCE RECOMMENDATION?
___ Yes
___ No
13. FURTHER CARE – DISPOSITION (check one)
Ambulance to hospital
Went to Health Services
Left area, no info
Security to hospital
Went home on own
Continued activity
Self/Friend to hospital
Friend to home
Witness: ______________________ Phone: _____________ Address: ____________________________________________
Refusal of Service (Signature of Injured):______________________________________________ Date: __________
Signature of Report Filer: __________________________________________________________ Date: __________
Follow-
up: Write comments on the reverse side of this report, sign and date.
INJURY REPORT FORM
PLEASE PRINT
Accident Date: ____/____/____
Time: ________ am/pm
Sex: M ___ F ___
Name of Injured: ______________________________ Phone: ___________________ I.D. # _________________________
Permanent Address: ______________________________________________________________________________________
Name of Area Supervisor: _________________________________________________________________________________
1. CLASSIFICATION OF INJURED (check one)
Student
Faculty/Staff
Member
Guest
Employee
2. IS THE INJURED A MINOR?
___ Yes ___ No
3. ACCIDENT LOCATION (check one)
Recreation Center
Outdoors
Other (specify)
4. ACTIVITY AREA OF ACCIDENT (check one)
Aerobics Room
Locker Room
Weight Room
Fitness Area
Pool
Outdoor Tennis
Rec Fields, __________
Gym
Racquetball Court
Track
Other (specify)
5. PROGRAMMER (check one)
Personal Fitness
Informal Recreation
Instructional Programs
Rec Sports
Sports Club
Other (specify)
6. ACTIVITY AT TIME OF ACCIDENT (check one)
Aerobics
Football
Softball
Weight Training
Basketball
Racquetball
Swimming
Other (specify)
Diving
Soccer
Volleyball
7. CAUSE OF ACCIDENT (check one)
Collision with obstacle (wall, post, etc)
Hit by striking implement (racquet, etc)
Collision with person
Previous Injury
Fall
Sudden turn, twist, or stop
Hit by projectile (ball, bat, etc)
Other (specify)
8. TYPE OF INJURY SUSPECTED IF KNOWN (check any that apply)
Bruise
Dislocation
Laceration
Other (specify)
Concussion
Fracture
Sprain/Strain
9. BODY PART INJURED (note side of injury using “R” for right side and “L” for left side)
___ Abdomen
___ Face
___ Head
___ Shoulder
___ Up. Leg
___ Ankle
___ Fingers
___ Knee
___ Thumb
___ Wrist
___ Back
___ Foot
___ L. Arm
___ Toes
___ Elbow
___ Hand
___ L. Leg
___ Trunk
___ Eyes
___ Hip
___ Neck
___ Up. Arm
10. BLOOD EXPOSURE (check one)
_____ Yes
_____ No
Name/Phone: ________________________
11. FIRST AID RENDERED (check all that apply)
CPR/Rescue Breathing
Stopped bleeding
None rendered
Gave Ice
Washed wound
Other (specify)
Kept immobile
Victim of self-care
12a. WAS AN AMBULANCE RECOMMENDED TO BE CALLED?
___ Yes
___ No
12b. IF YES TO 12a, DID THE VICTIM REFUSE AMBULANCE RECOMMENDATION?
___ Yes
___ No
13. FURTHER CARE – DISPOSITION (check one)
Ambulance to hospital
Went to Health Services
Left area, no info
Security to hospital
Went home on own
Continued activity
Self/Friend to hospital
Friend to home
Witness: ______________________ Phone: _____________ Address: ____________________________________________
Refusal of Service (Signature of Injured):______________________________________________ Date: __________
Signature of Report Filer: __________________________________________________________ Date: __________
Follow-
up: Write comments on the reverse side of this report, sign and date.

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