Injury Report Form printable pdf download

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

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