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 Name
Last Name
Age of Injured Player
*
Players Age Level
*
Tykes (6U)
Mites (8U)
Squirts (10U)
Pee Wee (12U)
Bantams (14U)
High School
Girls (6U)
Girls (8U)
Girls (10U)
Girls (12U)
Girls (14U)
Girls (16U)
Girls (18U)
Girls High School
Players Association
*
IOWA
Ames Minor Hockey Association
Bucs AAA
Cedar Rapids Youth Hockey
Des Moines Youth Hockey Association
Des Moines Adult Hockey Associations
Dubuque Youth Hockey Association
Iowa City Hockey
Iowa Wild AAA
Lakes Area Hockey Associative (Okoboji)
Mason City Youth Hockey
Quad City Hockey Associative
Quad City Sled Hockey
Sioux Center Hockey Association
Siouxland Youth Hockey Association
Waterloo Youth Hockey Associative
Waterloo Adult Hockey Associations
KANSAS
Kansas City Youth Hockey Association
KCIC Adult League Hockey Associations
Mid America High School League
Mid American Adult Hockey Association
Northland Adult Hockey
Topeka Youth Hockey Association
Wichita Youth Hockey Association
Wichita Adult Hockry League
NEBRASKA
Fremont Youth Hockey
Lincoln Ice Hockey Association
Omaha Hockey Club
Omaha AAA
Tri-City Youth Ice Hockey Associative
Tri-City Senior Hockey League
Summer League Team
Players Team
*
IOWA
Ames House
Ames Flyers
Boji House
Boji Blizzard
Boji Mammouth
Cedar Rapids House
Cedar Rapids Jr. Roughriders
DMYHA - Beginners
DMYHA - House League
DMYHA - Select
DMYHA - Jr. Bucs
DMYHA - Capitals
DMYHA - Oak Leafs
DMYHA - Lady Wild
DMYHA HS Club - Dowling
DMYHA HS Club - Lincoln / Roosevelt
DMYHA HS Club - Valley
DMYHA HS Club - Waukee / Norwalk
Dubuque House
Dubuque Jr. Saints
Dubuque Devils
Iowa City House
Iowa City Blizzard
Iowa City Maidens
Iowa Wild AAA
Mason City House
Mason City Mohawks
Quad City House
Quad City Ice Eagles
Quad City Blues
Sioux Center House
Sioux Center Tornados
Sioux City IP / House
Sioux City Jr. Musketeers
Sioux City Metros
Waterloo Little Hawks
Waterloo Jr. Hawks
Waterloo Warriors
Waterloo Adult Hockey
KANSAS
KC Carriage Club
KCYHA - House
KCYHA - St. Joseph
KCYHA - Jr. Mavs
KCYHA - Mavericks A
KCYHA - Mavericks AA
KCYHA - Mavericks Midgets
KCYHA - Rockhurst
KCYHA - Saints
KCYHA - Stars
KCYHA - Jets
KCYHA - Storm
KCIC Adult Hockey
Mid American Adult Hockey
Northland Adult Hockey
Wichita House
Wichita Jr. Thunder
Wichita Adult Hockey
NEBRASKA
Fremont House
Fremont Flyers Select
Fremont Flyers
HS Club - Fremont
Lincoln House
Lincoln Jr. Stars
HS Club - Lincoln
Omaha House
Omaha Jr. Lancers
Omaha Jr. Mavericks
Omaha Lady Jr. Lancers
Omaha AAA
Omaha HS Club - Creighton Prep
Omaha HS Club - Elkhorn
Omaha HS Club - Metro
Omaha HS Club - Millard North
Omaha HS Club - Millard South
Omaha HS Club - Millard West
Omaha HS Club - Papillion
Omaha HS Club - Westside
Tri-City House
Tri-City Jr. Storm
HS Club - Tri-City
Tri-City Adult
Summer League Team
Date of Injury
*
-
Month
-
Day
Year
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 Name
Last Name
Submitting Person’s Email
*
example@example.com
Submitting Person’s Cell Phone Number
*
-
Area Code
Phone Number
Date Injury Reported (Today’s Date)
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: