Incident Form

Sports Incident Report
Section I: Incident Details
Date and Time of Incident:
Date

MonthDayYear
Date
Time
Location:
Facility Field
Specific Area
Weather Conditions:
Temperature
Rain/Weather Conditions
Section II: Involved Parties
Person Reporting the Incident:
Name
Position/Role
Contact Information
Injured/Involved Person(s):
Name(s)
Age(s)
Team/Group
Contact Information
Witnesses:
Name(s)
Contact Information
Section III: Incident Description
Nature of Incident:

Slip/Trip/FallCollision with Another PlayerEquipment FailureMedical EmergencyOther
Description of Incident:
(Provide a detailed account of what happened including the events leading up to the incident, the incident itself, and any immediate actions taken.)
Section IV: Injuries and Medial Assistance
Injuries:
Severity:

MinorModerateSevere
Medical Assistance

First Aid ProvidedEmergency Medical Services (EMS) CalledTransported to HospitalNo Medical Assistance Required
Name of Medical Personnel Involved:
Name(s)
Contact Information
Section V: Actions Taken
Immediate Actions:

Notified Emergency ServicesNotified Parent/GuardiansCompleted Incident FormOther
Section VI: Follow-Up
Further Investigation Required:

YesNo
If Yes, Describe Further Steps:
Section VII: Additional Documentation
Attachments:

PhotosVideo FootageWitness StatementsOther
Signature of Person Reporting

Clear
Date

MonthDayYear
Date
File Upload

Cancelof
Should be Empty:

Sports Incident Report