Incident Report

Report of Injury / Incident

To be used for reporting Major or Minor Injuries AND/OR Damage to Property/Others.
Name of Coach: *

First Name Last Name
Class Type:*

PK 4 KIDSPK Silver (Licenees Only)PKSCS (Specialists Only)
Shift Start Time:

:Hour Minutes AM/PM Option
Time of Injury / Incident:

:Hour Minutes AM/PM Option
Time Injury / Incident was Reported to Supervisor:

:Hour Minutes AM/PM Option
Injury Reported to: *

First Name Last Name
Type of Incident:*

Minor Injury (scrapes, cuts, bruises, strains/sprains, etc.)Major Injury (fracture/break, concussion, dislocation, subluxation, etc.)
Details of Incident(part of body/which equipment affected/how did it occur): *

0/0
Witness(es) (If none, write "None"): *
Phone Number of Witness:

Report of Injury / Incident