Accident Report

INSTRUCTIONS: This report must be completed by the players Head Coach and submitted within forty eight (48) hours from the time of injury.

Division

Enter your team age group and name. example - U14-White

Coaches Name

First Name

Last Name

ACCIDENT INFORMATION

Injured Players Name

First Name

Last Name

Date

Enter in the date of the injury

YYYY

Time

Enter in the estimated time of the injury

Hour

Minute

Second

Accident Location

Indicate the park name

Type of Event

Please select only one event type

Practice

Jamboree/Game

Other

Location of Injury

Example: Right Hand - 3rd Finger

Brief Description of the Injury

Example: While trying to catch a ball, finger got jammed. Player was able to bend all fingers, but was in pain and started to swell and bruise.

What Type of First Aid was Administered?

Example: Placed an ice pack on the hand and advised parents to take the player to hospital for further examination.

ACCIDENT REPORT