Incident Report Form

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S
O
PECIAL
LYMPICS
F
R
A
/ I
IRST
EPORT OF
CCIDENT
NCIDENT
U.S. Program/Area: ____________________________ Date of Incident: _____________
Type of Injury/ Accident:
Injured Party:
Injured Person/Party Information
Date of Birth: ____/_____/_____
Age: ______
 Bodily Injury
 Athlete
 Volunteer
 Property Damage
Name: _____________________________________________________________________
 Coach
 Automobile
(Last)
(First)
(MI)
 Employee
 Other: _______________
Address: ___________________________________________________________________
 Spectator
(Street)
(City)
(State)
(Zip)
 Unified Partner
 Property Owner
Home Phone: (______)_______-________ Work Phone: (______)________-____________
 Other: _______
Gender:  Male
 Female
Social Security Number: ______-____-________
Description of Accident
(If automobile accident occurred, please attach a copy of the police report).
Describe how the accident occurred
_____________________________________________________________
(Attach a separate sheet if necessary):
__________________________________________________________________________________________________________________
__________________________________________________________
Sport
___________________________________________________________
 Alpine Skiing
 Power Lifting
 Aquatics
Site / event where accident occurred: _____________________________
 Relay Game
Body Part Injured:
 Head
 Athletics
 Roller Skating
 Neck
 Badminton
 Sailing
Disposition:
 Torso
Accident Occurred During:
 Baseball
 Snowboarding
 Released to parent
 Training/Practice
 Back
 Basketball
 Snowshoe
 Refusal of care
 Competition
 Hand
 Bocce
(L / R)
 Soccer
 Refer to doctor
 Traveling to or from SO event
 Finger
 Bowling
 Softball
(L / R)
 Refer to hospital or clinic
 Other: __________________
 Elbow
 Cheerleading
 Speed Skating
(L / R)
 Medical attention
 Shoulder
 Cross Country
 Swimming
(L / R)
 EMS transport
Type of Injury:
 Leg
 Table Tennis
(L / R)
 Severe cut w/ bleeding
Ski
 Patient requested EMS transport
 Knee
 Cycling
 Team Handball
(L / R)
 Less serious bruise or cut
 Released to personal vehicle
 Thigh
 Equestrian
 Tennis
(L / R)
 Break/fracture
 Police
 Shin
 Figure Skating
 Track & Field
(L / R)
 Concussion
 Ambulance
 Toe
 Floor Hockey
 Volleyball
(L / R)
 Paralysis
 Report only
 Other: _____________
 Golf
 Other: ________
 Fatality
 Other:
 Gymnastics
 Other:
Contact / Care Provider Information
If an athlete or underage volunteer was injured, please identify the care provider and/or responsible party (e.g. parent, legal
guardian).
Relationship to the injured person: _________________________
Employer Name: __________________________________________
Name: _______________________________________________
Employer Address: ________________________________________
Address: _____________________________________________
________________________________________________________
_____________________________________________________
Work Phone: (______)________-___________
Home Phone: (______)_______-________
 Yes  No
Does the injured person have medical insurance?
 Injured Person  Care Provider/Responsible Party
If yes, insurance is provided by:
Please provide name of Company and Policy Number: __________________________________________________
Witness Information
(Please provide names and phone numbers of any witnesses to the incident)
Witness #1 Name: _________________________________________________
Daytime Phone: (______)_______-________
Witness #2 Name: _________________________________________________
Daytime Phone: (______)_______-________
Special Olympics Official / Representative
(other than claimant)
Name: __________________________________________________________
Daytime Phone: (______)_______-________
Signature: _______________________________________________________
Send completed form to:
American Specialty Insurance Services, Inc., P.O. Box 459, Roanoke, IN 46783-0309; Fax: (260) 673-1291
If injury was serious or a fatality:
IMMEDIATELY notify American Specialty Insurance Services, Inc.
Telephone: (800) 566-7941 (24 hours a day / 7 days a week)
AMER: 189207 –SpecOlym Inc. Rep.Form 03-04

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