Aca Incident / Accident Report Form printable pdf download

ACA Incident / Accident Report Form

If additional space is needed, please attach a separate piece of paper.

DATE OF INCIDENT________ TIME OF INCIDENT______AM/PM

DOES THE INJURED PERSON HAVE OTHER MEDICAL

 YES

 NO

Name of Club:_______________________________

INSURANCE?

Address:____________________________________________________

If yes, please provide name of company and policy #:________________

Telephone Number:___________________________________________

____________________________________________________________

 Athlete

 Official

 Coach

INJURED PERSON:

DID THIS TAKE PLACE DURING:

 Practice

 Competition

 Club Activity/Event

 Spectator

 Employee  Volunteer

 Other ____________

 Pre-activity

 Sanctioned Activity/Event

Yes

No

Was injured person a member of organization?

 After activity

 While traveling

INJURED PERSON INFORMATION

 Single

 Married

Last Name

First

Middle

Telephone Number (

)

Address

Social Security Number (optional)

City

State

Zip

Employer and Address

 Male  Female

Age

D.O.B.

GUARDIAN/PARENT (IF INJURED PERSON IS A MINOR)

Last Name

First

Middle

Telephone Number (

)

Address

City

State

Zip

SUSPECTED PRE-EXISTING CONDITION:  Yes  No

INCIDENT LOCATION

INCIDENT

MEDICAL SERVICES

 Competition area

 Concession area

 Assault/Sexual

 Slip, bodily reaction

 Antacid

 Eye rinse

 Parking lot

 Admission area

 Assault/Non-Sexual

 Slip/Fall

 Aspirin

 Glucose

 Restrooms/locker rooms  Off property

 Fall (different level)

 Eligibility

 Aspirin substitute

 Ice Pack

 Premises/grounds

 Store area

 Fall (same level)

 Aquatic

 Bandaged

 Oxygen

 Bleachers/stands

Caught in, on, between

 Trip/Fall

 Ointment/antiseptic

 Rest

 Animal/insect bite/sting

 Drug Testing

 Removal

 Splinted

 Collision (with object)

 Overexertion

 CPR

 Wrapped

CLASSIFICATION

 Facility or event related

 Non-injury

 Collision (participant/participant)

 Cleansed

 Exam

 Not facility or event related

 Collision (participant/spectator)

 Cold Pack

 Minor injury or illness

 Collision (spectator/spectator)

 None

 Serious injury or illness

 Struck by falling/flying object

Auto/Property

Treated By: ______________________

PRIMARY INJURY

BODY PART INJURED

DISPOSITION

 Allergy

 Dislocation

 Nausea

 Eye

 Torso

 Arm (L/R)

 Released to parent

 Police

(L/R)

 Amputation

 Electrical Shock  Stroke

 Nose

 Back

 Tooth

 Refusal of care

 Ambulance

 Abrasion

 Foreign Body

 Burn

 Neck

 Face

 Head

 Refer to doctor

 Report only

 Laceration

 Fracture

 Death

 Ear

 Leg

 Refer to hospital or clinic

(L/R)

 Drowning

 Heat Exhaustion  Pain

 Knee (L/R)

 Ankle (L/R)

 Medical attention

 Hypertension

 Cardiac

 Illness

 Internal

 Hip

 EMS transport

(L/R)

 Cold Injury

 Contusion

 Sting/bite

 Shoulder (L/R)  Foot (L/R)

 Patient requested EMS transport

 Seizures

 Concussion

 Elbow (L/R)

 Hand (L/R)

 Released to personal vehicle

 Strain/Sprain

 Tooth/Mouth

 Wrist (L/R)

 Finger or Toe

Revised 02.02.2012

Aca Incident / Accident Report Form

Related Articles

Related forms

Related Categories