PAO - 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
Time of first aid
Hour Minutes
AM
PM
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)
Person Completing Report
First Name
Last Name
Signature of person completing report
Supervising Coach Signature
Witness Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: