Player Agent:
First Name
Last Name
Accident Report
In case of injury, this form must be filled out as soon as possible. By filling out this form, the Player Agent will be notified upon its submission. Remember: ONLY PROVIDE TREATMENT YOU ARE QUALIFIED TO PROVIDE.
Player Agent Phone Number:
-
Area Code
Phone Number
Player Agent E-Mail:
example@example.com
Injured Person
Enter information about the person who was injured or is experience COVID symptoms.
Name:
*
First Name
Last Name
Age:
*
Sex:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
Phone Number
Parent/Guardian Name (if minor):
First Name
Last Name
Was Parent/Guardian notified (if minor)?:
Yes
No
Location Of Accident/Incident
Describe the location of where the accident/incident occurred (if known or applicable)
Name of field:
*
i.e. Levy Field 1
Where on field:
*
i.e. Third Base, Field 1
Draw Map of where accident/incident occurred (Optional):
Description of Accident/Incident
Describe how accident/incident occurred. Include any unsafe conditions, use of equipment, or other items, such as any statements made by the injured party.
Accident/Incident Description and Details:
*
Back
Next
Witnesses
Provide contact information for person(s) who witnessed the accident/incident.
Witness Name 1:
*
First Name
Last Name
Witness Address 1:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Witness Phone Number 1:
*
-
Area Code
Phone Number
Witness Name 2 (optional):
First Name
Last Name
Witness Address 2 (optional):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Witness Phone 2 (optional):
-
Area Code
Phone Number
Witness Name 3 (optional):
First Name
Last Name
Witness Address 3 (optional):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Witness Phone 3 (optional):
-
Area Code
Phone Number
Back
Next
Possible Injury/Sickness
Describe the possible nature of the injury or sickness.
Possible Injury/Sickness Type:
*
Fracture
Sprain
Dislocation
COVID
Other
Possible Injury Area:
*
Arm
Elbow
Wrist
Thigh
Knee
Ankle
Head
Back
Internal
Other
Possible Injury Location:
*
Right
Left
Upper
Lower
Internal
Treatment (Rescue)
Describe treatment and injured party's status.
Treated By:
*
i.e. John Doe, EMT, etc.
Treatment Description and Status:
*
Was 911 called?
*
Yes
No
911 was called by whom (if applicable)?:
First Name
Last Name
Back
Next
Conditions
Provide weather conditions or other factors that would help explain the environment in which the accident/incident happened.
Description of conditions:
*
Pictures Taken
Provide information regarding any pictures that were taken.
Were pictures taken?
*
Yes
No
Pictures taken by whom (if applicable)?:
First Name
Last Name
Date pictures were taken (if applicable):
-
Month
-
Day
Year
Date
Time pictures where taken (if applicable):
1
2
3
4
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Hour
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Minutes
AM
PM
AM/PM Option
Upload any pictures here (if applicable):
Browse Files
Cancel
of
Comments
Provide any other comments you would like to share that would help with the accident/incident investigation.
Additional Comments:
*
Back
Next
Accident/Incident Reporter and Signature
Reporter Name:
*
First Name
Last Name
Reporter E-Mail:
*
example@example.com
Reporter Signature:
*
Date Reported:
*
-
Month
-
Day
Year
Date
Time Reported:
*
1
2
3
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9
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Hour
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Minutes
AM
PM
AM/PM Option
Please Verify That You Are Human
*
Submit
Should be Empty: