ACCIDENT/INCIDENT REPORT FORM

ACCIDENT/INCIDENT REPORT FORM
DateTime
This form is to be used when any accident and/or unusual incident occurs causing
injury to a person, damage to a facility, and/or potential risks to individuals while
under Stateline Sports Group jurisdiction. Completion of this form is necessary to provide
proper documentation in case of potential legal action.
Name of Person Filing The Report.*

First NameLast Name
Name of Person Filing The Report Email*
example@example.com
Name of Person Filing The Report Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Select One*

IncidentAccident
Date Of Occurrence*

MonthDayYear
Date
If Accident Name Of Person Injured

First NameLast Name
Site Of Occurrence*
Time of Occurrence*
Where did incident/accident occure?*

PracticeGame
List witnesses present:
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
FOR INCIDENTS/UNUSUAL OCCURANCES ONLY
Describe Incident
Describe Action Taken
List in detail any damage to facility or equipment
FOR INJURY REPORTS ONLY
Describe how the injury occured
Type of Injury

AbrasionBruseBurnCutSprainDislocationConcussionOther
Body part injured:

HeadArmBackTorsoSprainHand/WristLegOther
ACTION TAKEN FOR INJURED PERSON
Immediate Firts Aid Administered?

YesNo
By

First NameLast Name
Signature of person filing report*
Should be Empty:

List witnesses present: