For Local League Use Only
Activities/Reporting
A Safety Awareness Program's Incident/Injury Tracking Report
League Name:
League ID:
Incident Date:
-
Month
-
Day
Year
Date
Field Name/Location:
Incident Time:
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Injured Person's Name:
Date of Birth:
-
Month
-
Day
Year
Date
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age:
Sex:
Male
Female
Home Phone:
-
Area Code
Phone Number
Parent's Name (If Player):
Work Phone:
-
Area Code
Phone Number
Parents' Address (If Different):
City
Incident occurred while participating in:
Baseball
Softball
Challenger
TAD
Challenger
T-Ball
Minor
Major
Intermediate (50/70)
Junior
Senior
Big League
Tryout
Practice
Game
Tournament
Special Event
Travel to
Travel from
Other
Position/Role of person(s) involved in incident:
Batter
Baserunner
Pitcher
Catcher
First Base
Second
Third
Short Stop
Left Field
Center Field
Right Field
Dugout
Umpire
Coach/Manager
Spectator
Volunteer
Other
Type of injury:
Was first aid required?
Yes
No
If yes, what:
Was professional medical treatment required?
Yes
No
If yes, what:
(If yes, the player must present a non-restrictive medical release prior to to being allowed in a game or practice.)
Type of incident and location: A.) On Primary Playing Field
Base Path:
Running
Sliding
Hit by Ball:
Pitched or
Thrown or
Batted
Collision with:
Player or
Structure
Grounds Defect
Other
B.) Adjacent to Playing Field
Seating Area
Parking Area
Volunteer Worker
Customer/Bystander
D.) Off Ball Field
Travel:
Car or
Bike or
Walking
League Activity
Other
Please give a short description of incident:
Could this accident have been avoided? How:
This form is for local Little League use only (should not be sent to Little League International). This document should be used to evaluate potential safety hazards, unsafe practices and/or to contribute positive ideas in order to improve league safety. When an accident occurs, obtain as much information as possible. For all Accident claims or injuries that could become claims to any eligible participant under the Accident Insurance policy, please complete the Accident Notification Claim form available at http://www.littleleague.org/Assets/forms_pubs/ asap/AccidentClaimForm.pdf and send to Little League International. For all other claims to non-eligible participants under the Accident policy or claims that may result in litigation, please fill out the General Liability Claim form available here: http://www.littleleague.org/As- sets/forms_pubs/asap/GLClaimForm.pdf.
Prepared By/Position:
Phone Number:
-
Area Code
Phone Number
Signature:
Date:
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: