In-Game Injury Notification

"In-Game" Injury Notification
Please use this form to record an injury for the purposes of informing IHSA of in game injury. A copy of this report will be sent to IHA for record keeping.

Please note - This IS NOT an official Injury Report form for Insurance Purposes. You will receive links and information to help you make an insurance claim, if required, once this report is submitted.

Injury Definition
1. An injury is considered reportable if a player a misses a training or a game because of an injury sustained during a practice or game.
2. The player does not return to play for the remainder of the game following an injury.
3. All concussions.
4. Any dental injury.
5. Any facial laceration.
Who is completing this form?

Injured Party / Parent / GuardianWitness
Game Date & Time*

DayMonthYear
Date
Hour MinutesAM/PM Option
Association
Venue*

Ice ArenAOther
Venue (If Other)*
League / Activity*

Senior Winter League (Club)Junior Winter LeagueSummer League (ASL)Women's League (AWL)Come and Try / DevelopmentClinicsOther
Grade*

PremA GradeB GradeC GradeDiv 1Div 213U16u / 17U9UIce BlastOther
Team Name
Player / Injured Party Name*
Age
Player Number
Position

CentreWingDefenceGoalOfficialBenchOther
Did the Player Leave the Game?*

No - Did Not Leave the GameYes - Left but returned later in the gameYes - Left and did not return
Was emergency services called?*

NoYes
Was a Duty Manager called / advised?*

NoYesAttempted - DM could not be located
DM Name
If you do not know the name, please enter "Unknown".
Was First Aid requested of the Duty Manager?

NoYes
Was a First Aid provided by the Duty Manager?

NoYes
Zone of Injury:
Mark the area of the ice surface where the injury occurred. Note that Home and Visitor ends are marked to identify offensive and defensive activity.

Injury Type & Severity*

	EMS Called	First Aid Provided on Site	No First Aid Provided
Head / Face / Skull / Dental
Back / Neck
Trunk / Torso
Arm / Shoulder
Leg / Knee /Foot
Pelvis / Groin / Hip

Location of the Injury

HeadFaceNeckThroatJaw/ChinTeeth/MouthEyeEarShoulderUpper armElbowForearmWristHandThumbFingersChestAbdomenKidneysUpper backLower backCoccyxButtocksPelvisGroinGenitalsHipThighKneeLegAnkleFootToes
Assessment

NoneContusionSprain - ligamentSprain - muscleLacerationDislocationFractureConcussionOther
Was The Injury:

MinorAcuteSevere
Cause of Injury

Cause of InjuryBody CheckCheck from behindCheck to the head/neckStick contactPuck contactUnintended collisionFightingNon-contactOther
Was a Penalty Called?

YesNo

Equipment*

	Yes	No
Full Face Mask
Visor
None
Mouth Guard
Neck Guard

Time Lost: (The amount of time the player was out of play)

Return the same gameReturn the same dayOut for the ChampionshipOne week or more
Any comment?
Include details of any first aid provided on site.
Your name*
Would you like to receive a copy of this report?

Yes (include your email address below)No
Your Email
example@example.com (for follow up if required)
Please Note

Where the injury may result in a claim, then the player needs to lodge their claim with AJG within thirty (30) days of occurrence.
Should be Empty:

"In-Game" Injury Notification