Injury

Report Form
Player Name: ______________________________________ Phone Number: ___________________________
Gender: M F D.O.B.: ___/___/_____ Date: ____/____/____ Time: ___:___ am / pm
Event: Game Practice Location: _______________________ Team: ______________________
Team Official Present: Coach Manager Assistant Coach

TYPE OF ACTIVITY: SUSPECTED CAUSE OF INJURY: ADVICE GIVEN
Training
Warm-up Collision with fixed object Unable to return at present
Competition Collision with another player
Cool-down Fall from height/awkward landing Jumping Referred for further assessment before
Other: ____________________ to shoot or defend Overexertion returning to activity
Overuse
INJURY STATUS:
Slip/trip/fall/stumble Immediate return to activity
New injury
Struck by ball/object
Aggravated injury
Temperature related Return to play with restrictions
Recurrent injury
Other: _______________________ ___________________________________
Illness
_____________________________ ___________________________________
Other: _____________________
________________________________

BODY PARTS INJURED EXPLAIN HOW THE INCIDENT OCCURRED NOTICE The injured person was advised
Circle and Name ________________________________ that if the injury/illness does NOT improve
________________________________ in the following 24 hours they MUST seek
________________________________ further medical advice from their medical
________________________________ professional.
________________________________
________________________________
Yes No

IN YOUR OPINION, WERE THERE ANY
CONTRIBUTING FACTORS TO THE INCIDENT? i.e. Signature of Team Official:
unsuitable footwear, playing surface, equipment,
foul play. X: _________________________
________________________________
________________________________ Date: ____/____/____
________________________________

_________________________________
NATURE OF INJURY/ILLNESS WAS PROTECTIVE EQUIPMENT WORN ON THE Signature of Witness (i.e. trainer, parent):
INJURED BODY PART?
Bruise/contusion Yes No X: _________________________
Cardiac problem Cold/flu Concussion
Dislocation/subluxation If yes, what? (mouthguard, etc.) Date: ____ /____ /____
Fracture (including suspected) Loss of ___________________________________
consciousness INITIAL ATTENDANCE None given Signature of Injured Person/Legal
Overuse injury CPR Dressing Immobilization Guardian:
Respiratory problem RICER
Skin injury Splint/sling Strapping/taping X: _________________________
Sprain (i.e. ligament tear) Transport from field
Strain (i.e. muscle tear) Unspecified SCAT2 Date: ____ /____ /____
medical condition Other: Other: ___________________________
______________________