Injury Report Form
Record injury or first-aid details for RCR training, games, or events (after any emergency call).
For emergencies call 000 first; this form is for recording after the event.
Incident details
Incident date and time
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Location of incident
*
Activity
*
Training
Game
Event
Other
Injured person
Injured person's name
*
First Name
Last Name
Age
*
Is the injured person under 18?
*
Yes
No
Parent/guardian details
Parent/guardian name
First Name
Last Name
Parent/guardian phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Injury and first aid
What happened and what injury or symptoms were observed?
*
Body area affected
*
First aid provided
*
Was the injured person taken to or seen by a doctor or hospital?
*
Yes — doctor or hospital visit occurred
No
Doctor or hospital visit
Doctor or hospital name and location
Visit date and time
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Outcome or follow-up advice
Reporter declaration
Your name
*
First Name
Last Name
Your role
*
Please Select
Staff
Coach
Referee
Volunteer
Other
Reporter signature
*
Date signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Report
Submit Report
Should be Empty: