Injury Report

Injury Report

Panther City Rugby
This form is to be completed within 48 hours of an athlete's injury. Once complete, you will be able to access (download) the appropriate claim form(s) to recieve finanical assistance with medical expenses associated with you rugby injury.

Note that benefits are only available on acute injuries that occur during approved Panther City Rugby and/or USA Rugby activities. Engagement in rugby activities in the absence of a PCR approved coach are not considered approved activities.

If you have questions please contact an Panther City Rugby administrator.
Athlete's Full Name *

First Name Middle Name Last Name Suffix
Athlete's Sex *
Athlete's Birth Date *

Month Day Year
Athlete's Age *
Rugby Program *
Athlete's School Team
Athlete's PCR Club Team
Community Activity
Coach's Name *
Date of Injury *

Month Day Year
Event Type *
When Did Injury Occur? *
Injury Was Reported To Who? *
Person's Name *
Injured Area *

Head / Face Neck Chest / Ribs Abdomen Upper Back (Thoracic) Lower Back (Lumbar) Shoulder / Upper Arm Elbow / Forearm Wrist / Hand / Finger Pelvis / Hip Thigh / Knee Lower-Leg / Ankle Foot / Toe Medical (non-musculoskeletal)
Side of Body

Right Side Left Side
Mechanism *

Allergic Reaction Contact, Tackle Contact, Ruck Contact, Maul Contact, Scrum Contact, Person-to-Person (not listed) Contact, Person-to-Object Non-Contact Unknown
Nature of Injury *

Concussion - No LOC Concussion - W/ LOC "Stinger" (loss of strength &/or feeling, one arm) Paralysis (unable to move &/or feel, 1+; limbs) Contusion (Bruise) Sprain/Strain, good function Sprain/Strain, decreased function Sprain/Strain, loss of function Dislocation/Subluxation Fracture, no obvious deformity Fracture, apparent deformity Abrasion Laceration Impaired Breathing Heart Attack Shock
Was the Athlete Treated Onsite *

Yes No
Type of Care Provided *
The Athlete Was: *

Removed from Participation Returned to Participation
Was the Athlete Referred for Follow-Up Care *

Yes No
Where Was The Athlete Referred? *
Please Provide Name of Facility / Person Athlete Was Referred To
Was Care Attained There

Yes No
Name Of Person Completing This Form *

First Name Last Name
Your Relation to Athlete *
Your Mobile Phone Number *
Your E-mail *
Should be Empty: