Injury Report Form

Injury Reporting Form
The USA Hockey / Midwest Amateur Hockey Association Injury Management Protocol and the state statutes recommends that an athlete be removed from any training, practice or game if they exhibit any signs, symptoms or behaviors consistent with an injury. (This is NOT the correct form to Report a Concussion) The player should not return to physical activity until he or she has been evaluated by a qualified licensed medical provider who has provided clearance to return to sports.
This form is to be used after an athlete has been removed from athletic activity due to a suspected injury (Non-Concussion Related) to report data to the MWAHA Player Safety Coordinator for use in the USA Hockey Player Safety Initiative.
Name of Injured Player*

First NameLast Name
Age of Injured Player*
Players Age Level*
Players Association *
Players Team*
Date of Injury*

MonthDayYear
Date
Description of Injury (Please provide IN DETAIL what the player injured & how the injury occurred.)*
Upload Video or Picture (If Available) of the Concussion as it happened.

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Location of Injury: City, State & Arena / Ice Rink Name*
Name of Person Submitting Form*

First NameLast Name
Submitting Person’s Email*
example@example.com
Submitting Person’s Cell Phone Number*

Area CodePhone Number
Date Injury Reported (Today’s Date)*

MonthDayYear
Date
Should be Empty:

Injury Reporting Form