SSGT Student Course Registration Form

SSGT Course Injury Form

Fill out the form carefully for registration
Today's Date*

MonthDayYear
Date
Date the injury took place!*

MonthDayYear
Date
Injured Participants Name*

First NameMiddle NameLast Name
Injured Participant's Birth Date*

MonthDayYear
Injured Participant's Gender*
Injured Participant's Agency Name*
Injured Participant's Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Injured Participant's Department E-mail*
example@example.com
Injured Participant's Personal Email*
example@example.com
Injured Participant's Work Number*
Name of the Course Host Agency?*
Name of Course Lead Instructor?*
Course Lead Instructor's Phone?*
Please enter a valid phone number.
Course Lead Instructor's Email*
example@example.com
Course Lead Instructor's Agency, Department or Organization*
List all Co-Instructors present when the injury occurred!*
The course in which the injury took place was an Instructor Level Course or a Student/Operator Level Course!*
Choose the specific SSGT Course in which the injury took place!*
1. Yes or no! Was an instructor present when the injury occurred?*
2. How many participants were present when the injury occurred?*
3. Was medical treatment necessary for the injured party?*
4. Explain, in detail, the type of injury incurred!*
5. Explain, in detail, how the injury occurred!*
6. Yes or no. Was immediate and proper aid given to the injured party?*
7. Yes or no. Were appropriate training mats provided and used during this course? Write N/A if this was a firearms course.*
8. Yes or no. Were the participants taken through a 10 to 15 minute warm-up and stretching period? Write N/A if this was a firearms course.*
9. Yes or no. Was the course conducted in accordance with current SSGT training guidelines?*
10. Yes or no. I affirm that the preceding information is both accurate and correct.*
Additional Comments
Should be Empty:

SSGT Course Injury Form