INJURY REPORT FORM

Date of Injury: ____________________________ Time of Injury:______________________________

Event: __________________________________ Venue: ____________________________________
Type of Activity: Game / Practice / Tryout / Other
SECTION A: PERSON INJURED Player / Official / Coach / Spectator / Other
First Name:______________________________ Last Name: _____________________________ DOB:______________ Age: _______
Address: _______________________________________________________ Phone: ______________________ Email: __________________________________
SECTION B: INJURY DETAILS
Body Part(s) Injured Nature of Injury Signs & Symptoms
Tick or circle body part(s) injured  Abrasion/scrape  Bleeding
 Sprain (ligament injury)  Swelling
 Strain (muscle injury)  Bruising
 Open wound/laceration  Obvious deformity
 Bruise/contusion  Pain
 Swelling  Loss of feeling/sensation
 Fracture (suspected or confirmed)  Weakness
 Dislocation/subluxation  Dizziness
 Overuse/recurring injury  Shortness of breath
 Blisters  Fainting
 Concussion/head injury  Loss of consciousness
 Cardiac problem  Other
 Respiratory problem ________________________________________
 Loss of consciousness ________________________________________
 Unspecified medical condition ________________________________________
 Other ________________________________________
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Cause of Injury Please explain how the injury occurred (events Location on Pitch
 Contact/collision leading up, protective equipment or lack of,
 Non-contact contributing factors):
 Fall/slip/trip ___________________________________________
 Gradual onset, no specific mechanism ___________________________________________
 Temperature-related ___________________________________________
 Medical condition ___________________________________________
 Unknown ___________________________________________
 Other ___________________________________________
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Protective Equipment Worn? Yes / No
Initial Treatment Advice Given Anticipated Injury Time Loss
 None required  Return to play, no restrictions  0 days
 PIER (Pressure, Ice, Elevation, Rest)  Return to play with restrictions/support  1-5 days
 Bandaging  Unable to return to play  5-10 days
 Sling/splint Referral  10+ days
 Taping  None Notes
 Removal from play  Athletic therapy/physiotherapy ________________________________________
 Referral  Medical doctor ________________________________________
 CPR/AED  Ambulance/EMS ________________________________________
 Home advice  Hospital/emergency room
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 Other _______________________________  Urgent care
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______________________________________  Other _______________________________
SECTION C: SIGNATURES
Witnessed By:
Name: _____________________________________ Phone: ________________________ Email: __________________________________________
Signature: __________________________________ Date: __________________________
Reported By:
Name: _____________________________________ Phone: ________________________ Email: __________________________________________
Signature: __________________________________ Date: __________________________
Treatment Provided By:
Name: _____________________________________ Phone: ________________________ Email: __________________________________________
Signature: __________________________________ Date: __________________________