INJURY REPORTING FORM

INJURY REPORTING FORM
One form must be completed for each "injury" is defined as: Any ice hockey related ailment, occurring on the rink or player's bench, that kept (or would have kept) a player out of practice or competition for 24 hours or required medical attention (trainer, nurse or doctor) and all concussions, lacerations (cuts), dental, eye and nerve injuries.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Trainer/MD Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position played at time of injury (W, C, D, G)*
Game opponent (team)*
Time of injury (Warm-ups, 1, 2, 3, OT, After)*
Game frequency (1st, 2nd, 3rd, etc. game of event)*
TYPE OF INJURY*

ContusionFractureLacerationDislocationStrainConcussionSprainOther
BODY PART AFFECTED*

Head/ScalpChestFace/NoseAbdomenEye(s)Back/SpineMouth/TeethButtocksNeck/EarGroinShoulderHipArm/ElbowLeg/KneeWristAnkleHand/FingerFoot/Toe
INJURED'S CATEGORY*

PlayerCoachRefereeManagerVolunteerSpectatorOther
INTENT TO INJURE?*

YESNO
PENALTY CALLED?*

YESNO
NEW INJURY?*

YESNO
HOW INJURY OCCURRED*

Contact with boardsContact with goal/netBody contact with another personCaused by a body checkIncidental to playing puck/ballStruck by a stickContact with skateContact with floorStruck by puckNo apparent contactOther
Annotate Image*
Brief description of injury (what happened):*
What action was taken for injury?*
Name of Person Treating*
Phone*
Format: (000) 000-0000.
Should be Empty: