ECHS - Injury Report Form

AHCS - INJURY REPORT FORM

Use this form to report student-athlete injuries. Please be as detailed as possible.
Name of person injured

First Name Last Name
Date of birth

Month Day Year
Date
Date when injury occurred

Month Day Year
Date
Date when injury is evident

Month Day Year
Date
Person injured

Athlete Coach Other
Gender

Male Female
Treatment and First Aid Rendered
First aid provided bySignature

Clear
Time of first aid

Hour Minutes

AM/PM Option
Nature of injury

New injury Aggravated injury Recurrent injury Other
Initial treatment

No treatment required CPR RICER Crutches Sling/splint Dressing Strapping Massage Stretching
Did the injury occur during...

Training Event Other
Symptoms of injury

Blister Bleeding nose Bruising/contusion Cut Graze/abrasion Sprain Strain Inflammation/swelling Cramp Suspected bone fracture/break Dislocation Concussion/head injury Loss of consciousness Respiratory problem Spinal injury Cardiac problem Electrical shock Burn Insect bite/sting Poisoning Other
Injury Details
How did the injury occur?

Collision with a fixed object Overbalance Overstretch Slip/trip Collision/contact with another person Fall from height/awkward landing fall/stumble on same level Other
Extra detail regarding how the injury occurred:
Was protective equipment worn on the injured body part?

Yes No
Follow up action:

None Medical practitioner/physiotherapist Hospital Ambulance Other
Reporter, Coach/Supervisor, and Witness Signature(s)
Signature of person completing form

Clear
Supervising Coach Signature

Clear
Witness Signature

Clear
Date

Month Day Year
Date
Should be Empty:

AHCS - INJURY REPORT FORM

Treatment and First Aid Rendered

Injury Details

Reporter, Coach/Supervisor, and Witness Signature(s)