Mavericks Hockey Association Injury Reporting Form

Mavericks Hockey Association Team Injury Reporting Form
The purpose of this form is to ensure that any injury that leads to a loss of ice time for a player is reported to the Director of Governance and Safety. Mavericks Hockey Association takes the health and safety of all our players very seriously and wants to guartantee that Mavericks Hockey Association is taking an active role in helping with the long term health and safety of our players.
Injured Player Information
Injured Player's Name *

First Name Last Name
Team Information *

Age Group Division
Type of Injury *
Area of body affected *
Injury Information
Date of Incident *

Year Month Day
at
Hour Minutes AM/PM Option Date Picker Icon
Location *
Amount of Playing time lost during game *
Summary of injury *
Player was directed by Team Staff to seek a Medical Assessment *

Yes No
Name of Person Reporting the Injury *

First Name Last Name
E-mail Address of Person Reporting Injury *
Role of Person Reporting the Injury on the Team *
The above information is for Mavericks Hockey Association's Injury Management Protocols and will be kept confidential and will only be used to track number of injuries, types of injuries and to assist with a player returning to play hockey.
Should be Empty:

Mavericks Hockey Association Team Injury Reporting Form