Club Sport Accident Report Form

This form should be utilized for all occurrences if an Athletic Trainer is not present.

All behavior based occurrences should be documented utilizing the incident report.

Position of Person Completing the Report
Basic Information
Date of occurrence. Date of occurrence. / MM / DD YYYY
Person Completing the Report Person Completing the Report First Last
Time of occurrence (roughly). Time of occurrence (roughly). : HH MM AM/PM
Location where Accident occured
Activity at Time of Occurrence (practice, competition, warm-up)
Contact Information for Injured Individual
Name of Injured Individual. Name of Injured Individual. First Last
Phone Number. Phone Number. - ### - ### ####
SU ID #
Must be a number less than or equal to 99999999999999.
Email Address.
If the injured individual is a minor (under 18), please submit their birth date. If the injured individual is a minor (under 18), please submit their birth date. / MM / DD YYYY
If the injured individual is a minor (under 18), please enter their age.
Injury Description
Nature of Injury
Site of Injury (Select All that Apply)

Site of Injury (Select All that Apply) Left Arm Right Arm Left Hand Right Hand Left Shoulder Right Shoulder Head Back Left Ankle Right Ankle Face Chin Left Hip Right Hip Left Knee Right Knee Left Leg Right Leg Torso Other Ear
Nature of Suspected Injury or Illness.
Was there bleeding?

Was there bleeding? Yes No
Care Rendered to Injured Individual.

Care Rendered to Injured Individual. Continued Participation Against Advice Refused Care Left Area Abruptly First Aid Provided Referred to on Duty Athletic Trainer Called SU Ambulance After Receiving Care, Individual Left on Own Left with SU Ambulance Given Ice Discontinued Activity
Describe the Accident. (What action(s) by the participant lead to the injury?)
Person Who Provided Care Person Who Provided Care First Last

Club Sport Accident Report Form

Club Sport Accident Report Form

Basic Information

Contact Information for Injured Individual

Injury Description