Injury or Concussion Report

Injury or Concussion Report

Activity Leader
This report is to be completed by the Activity Leader (Coach, Team Manager/Chaperone, Meet Managers, etc.)

Injury or concussion report
- Physical in nature
- First Aid administered
- Significant impact to head, neck, face or body
Your Name*

First NameLast Name
Email*

Confirmation Emailenter twice to confirm email address
Phone Number*
Role
coach, team chaperone meet manager, etc.
Date of injury
Where did the injury occur?*
include facility/competition name if applicable
Occured during*

TrainingCompetitionOther
Injury
Injured person*

First NameLast Name
Date of Birth
Contact Information
Phone & Email of injured person
Club Name
if applicable
The injured person was a*

SwimmerCoachOfficial / VolunteerNon-registrantOther
Was there any significant impact to the head, neck, face or body?*

YESNO
ACTION: The injured Person cannot continue to participate in the activity until assessed for possible concussion symptoms.

Concussion management protocols are in effect.

This report will be sent to Darin Muma for review - darin@swimontario.com

You will be contacted if futher details are needed.
Were symptoms of a concussion present?

YESNO
If symptoms are present or develop after return to the activity, the participant shall be removed from any further Swim Ontario sanctioned activity for the remainder of the day and only return to play once they receive Swim Ontario approval.
Injury details*
Supporting Documents

if applicable
Cancelof
Did the Injured person return to their activity?*

YESNO
This report will be sent to Darin Muma for review - darin@swimontario.com

You will be contacted if further details are needed.
Signature

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