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
Format: (000) 000-0000.
Name of the Course Host Agency?
Name of Course Lead Instructor?
Course Lead Instructor's Phone?
Please enter a valid phone number.Format: (000) 000-0000.
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