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?
  • Game Date & Time*
     - -
  • League / Activity*
  • Grade*
  • Position
  • Did the Player Leave the Game?*
  • Was emergency services called?*
  • Was a Duty Manager called / advised?*
  • Was First Aid requested of the Duty Manager?
  • Was a First Aid provided by the Duty Manager?

  • Zone of Injury:

  • Rows
  • Location of the Injury
  • Assessment
  • Was The Injury:
  • Cause of Injury
  • Was a Penalty Called?
  • Rows
  • Time Lost: (The amount of time the player was out of play)
  • Would you like to receive a copy of this report?

  • 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: