A Safety Awareness Program'S Incident/injury Tracking Report Form
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1A Safety Awareness Program’s
Activities/Reporting
Incident/Injury Tracking Report
League Name: _____________________________ League ID: ____ - ___ - ____ Incident Date: __________
Town of Newburgh Little League
232
19
03
Field Name/Location: _________________________________________________ Incident Time: __________
Injured Person’s Name: ______________________________________ Date of Birth: ___________________
Address: __________________________________________________ Age: ________ Sex:
Male
Female
City: ____________________________State ________ ZIP: ________ Home Phone: (
) _____________
Parent’s Name (If Player): ____________________________________ Work Phone:
(
) _____________
____________
Parents’ Address (If Different): _________________________________ City ___________________________
Incident occurred while participating in:
A.)
Baseball
Softball
Challenger
TAD
B.)
Challenger
T-Ball (5-8)
(4-7)
Minor (7-12)
(7-11)
Major (9-12)
Intermediate (50/70) (11-13)
Junior (13-14)
Senior (14-16)
Big League (16-18)
Senior (13-16)
Big League (15-18)
Junior (12-14)
C.)
Tryout
Practice
Game
Tournament
Special Event
Travel to
Travel from
Other (Describe): ________________________________________
Position/Role of person(s) involved in incident:
D.)
Batter
Baserunner
Pitcher
Catcher
First Base
Second
Third
Short Stop
Left Field
Center Field
Right Field
Dugout
Umpire
Coach/Manager
Spectator
Volunteer
Other: __________________
Type of injury: _____________________________________________________________________________
_________________________________________________________________________________________
Was first aid required?
Yes
No If yes, what:________________________________________________
Was professional medical treatment required?
Yes
No If yes, what: ____________________________
(If yes, the player must present a non-restrictive medical release prior to to being allowed in a game or practice.)
Type of incident and location:
A.) On Primary Playing Field
B.) Adjacent to Playing Field
D.) Off Ball Field
Base Path:
Running or
Sliding
Seating Area
Travel:
Pitched or
Thrown or
Car or
Bike or
Hit by Ball:
Batted
Parking Area
Player or
Collision with:
Structure
C.) Concession Area
Walking
Grounds Defect
Volunteer Worker
League Activity
Other: ____________________________________
Customer/Bystander
Other: ________
Please give a short description of incident: ____________________________________________________
_________________________________________________________________________________________
Could this accident have been avoided? How: __________________________________________________
This form is for Little League purposes only, to report safety hazards, unsafe practices and/or to contribute posi-
tive ideas in order to improve league safety. When an accident occurs, obtain as much information as possible.
For all claims or injuries which could become claims, please fill out and turn in the official Little League Baseball
Accident Notification Form available from your league president and send to Little League Headquarters in
Williamsport (Attention: Dan Kirby, Risk Management Department). Also, provide your District Safety Officer with
a copy for District files. All personal injuries should be reported to Williamsport as soon as possible.
Prepared By/Position: ____________________________________
Phone Number: (_____) _____________
Signature: _____________________________________________
Date: _____________________________
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