Incident/injuryreportform
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1
2Incident/Injury Report Form
Within 24 hours of Incident /Injury …
PLEASE complete both sides of the form and
Fax to Facility Scheduling @ 4904421 or email wambola@halifax.ca
General Information Person(s) involved PLEASE PRINT
Last Name:
First Name:
Gender:
______________
______________________________ ______________________________
Age (up to 19 yrs):
_______
Address:
_________________________________________________
Phone Number(s):
___________________
_________________________________________________
___________________
Physical Location where incident occurred PLEASE PRINT
Sport Facility Name:
___________________________
Address of Sport Facility: ________________________
Physical location – Describe the area on the field, in the building, etc. where the incident /injury happened:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Date & Time of Incident PLEASE PRINT
Date of Accident/Injury: Time of Accident/Injury:
____________________________________________
________________________________
Date Accident/Injury Reported: Time Accident/Injury Reported:
____________________________________________
________________________________
Description of Incident/Injury – PLEASE PRINT
How Incident /Injury Occurred please add sport being played:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Injury(s) – Detail location on body and type of injury(s):
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Description of First Aid Administered:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Damage to property; fields, buildings, etc. please provide as much information as possible:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Other:
Ambulance called: ___Yes __ No __Unknown __N/A
Medical Aid required: ___Yes ___No __Unknown __ N/A
Witnesses to the Incident/Injury PLEASE PRINT
Name:
_________________________________________
Phone Number:
___________________
Name:
_________________________________________
Phone Number:
___________________
Form Date: May 2012
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