Play as One - Injury Report Form

PAO - INJURY REPORT FORM

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

First NameLast Name
Date of birth

MonthDayYear
Date
Date when injury occurred

MonthDayYear
Date
Date when injury is evident

MonthDayYear
Date
Person injured

Other
Gender
Treatment and First Aid Rendered
First aid provided bySignature
Time of first aid

Hour Minutes

AM/PM Option
Nature of injury

Other
Initial treatment
Did the injury occur during...

Other
Symptoms of injury

Other
Injury Details
How did the injury occur?

Other
Extra detail regarding how the injury occurred:
Was protective equipment worn on the injured body part?
Follow up action:

Other
Reporter, Coach/Supervisor, and Witness Signature(s)
Person Completing Report

First NameLast Name
Signature of person completing report
Supervising Coach Signature
Witness Signature
Date

MonthDayYear
Date
Should be Empty:

PAO - INJURY REPORT FORM