Club Sport Accident Report Form

This form should be utilized for all occurrences in recreation facilities that result in bodily injury.

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

Basic Information
Person Completing the Report Person Completing the Report First Last
Position of Person Completing the Report
Date of occurrence. Date of occurrence. / MM / DD YYYY
Time of occurrence. Time of occurrence. : HH MM AM/PM
Facility Where the Accident Occurred.
Location in the Facility Where Accident Occurred.
Activity at Time of Occurrence.
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.
Address of Injured Individual. Address of Injured Individual.
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
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
Describe the Accident. (What action(s) by the participant lead to the injury?)
Person Who Provided Care Person Who Provided Care First Last
What action did Syracuse University staff take?
Name of Club Sport Professional Staff Member Contacted. Name of Club Sport Professional Staff Member Contacted. First Last
Date Professional Staff Notified. Date Professional Staff Notified. / MM / DD YYYY
Time Professional Staff Notified. Time Professional Staff Notified. : HH MM AM/PM
Archived Fields - Kept for Data Purposes

This is the description of your section break.
Name of injured individual. (Archived)
Site of injury: (Archived)
Care rendered to injured individual.

Care rendered to injured individual. Called Syracuse University Ambulance. Continued participation against advice. First Aid provided. Individual left area. Left with Syracuse University Ambulance. Referred to on Duty Athletic Trainer. Refused care.
Who provided care?
Name of Club Sport Professional Staff member contacted:

Club Sport Accident Report Form

Club Sport Accident Report Form

Basic Information

Contact Information for Injured Individual

Injury Description

Archived Fields - Kept for Data Purposes