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
Staff Member Filling Out Report Staff Member Filling Out Report First Last
Position of Staff Member Completing Report
Date of occurrence. Date of occurrence. / MM / DD YYYY
Time of occurrence. Time of occurrence. : HH MM AM/PM
Facility Where Accident Occurred. (Barnes Center, Tennity, Ernie Davis, etc.)
Location in the Facility Where Accident Occurred. (Climbing Wall, Basement WR, Men's Locker Room, etc)
Activity at Time of Occurence
Specific sport or activity at time of occurrence.
Contact Information for Injured Individual
Name of injured individual. Name of injured individual. First Last
SUID #
Must be a number less than or equal to 99999999999999.
Phone number: Phone number: - ### - ### ####
Email:
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, please submit their birth date. If the injured individual is a minor, please submit their birth date. / MM / DD YYYY
If the injured individual is a minor, 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
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)
Staff Member Who Provided Care Staff Member Who Provided Care First Last
What action did Syracuse University staff take?
Name of Barnes Center at The Arch Professional Staff Member Contacted Name of Barnes Center at The Arch Professional Staff Member Contacted First Last
Date Pro Staff notified. Date Pro Staff notified. / MM / DD YYYY
Time Pro Staff notified. Time Pro Staff notified. : HH MM AM/PM
Archived Fields - Kept for Data Purposes

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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 Barnes Center at the Arch Professional Staff member contacted:
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Accident Report Form

Accident Report Form

Basic Information

Contact Information for Injured Individual

Injury Description

Archived Fields - Kept for Data Purposes