Athletic Injury Report

THIS REPORT MUST BE SUBMITTED WITHIN 24 HOURS OF THE INJURY

An athlete who has been injured, and has required medical treatment, may not participate in any practice or athletic event for Eastern Christian until a medical clearance is provided by a medical doctor. The medical clearance must be on file in the Athletic Director's office prior to any participation.
Athlete Name*

First NameLast Name
Grade*
Sport*
Date of Injury*

MonthDayYear
Date
Time*

Hour Minutes

AM/PM Option
Site of Injury*

FieldGymPracticeGameLocker RoomBus
Body Part Injured
Head

Left EarRight EarLeft EyeRight EyeFaceHeadNeckScalp
Trunk

AbdomenBackChestGroinLeft ShoulderRight Shoulder
Extremities

LeftRightAnkleElbowFootHandLower ArmLower LegUpper ArmThumbHipKneeUpper LegWristFingerToes
Suspected Injury*

AbrasionBiteBruiseBurnLacerationCutDislocationFractureHeatStrainPunctureScratchShockSprainConcussionFaintedOther
First Aid Given By:*
First Aid Given*

Applied DressingApplied SplintKept ImmobileStopped BleedingWashed WoundObservedIceOther
Action Taken*

Returned to sportTaken to ER by parentsParent notifiedParent took homeAmbulance to hospitalTaken to doctor by parentCalled 9-1-1Other
Explanation of Accident*

Collision with personCollision with obstacleFallHit with ObjectExplanation of Accident:Injury to self
Describe specifically how the injury happened*
Witness Name*
Witness Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Name of coach submitting report*
Report Date*

MonthDayYear
Date
Signature of coach submitting report*

Clear
Date received by AD

MonthDayYear
Date
AD Signature

Clear
Date forwarded to nurse

MonthDayYear
Date
Nurse signature

Clear
Signature of Principal

Clear
Should be Empty:

THIS REPORT MUST BE SUBMITTED WITHIN 24 HOURS OF THE INJURY

Body Part Injured