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Albany Basketball Association Injury Report Form
Name of Person filling form out:
*
Name of Person Injured:
*
First Name
Last Name
Injured Person Phone Number
-
Area Code
Phone Number
Date
-
Month
-
Day
Year
Date
Person Injured:
*
Athlete
Coach
Team Manager
Spectator
Other
Time of Injury:
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
Time of First Aid:
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
Injury Reported to:
*
First Name
Last Name
Nature of Injury:
*
New Injury
Recurrent Injury
Aggravated Injury
Other
Symptoms of Injury:
*
Cut, Graze or and abraison
Sprain or Strain
Inflammation or Swelling
Suspected bone fracture or break
Suspected Dislocation
Concussion or Head Injury
Respiratory problem
Spinal Injury
Cardiac problem
Other
Details of Incident(part of body/which equipment affected/how did it occur):
*
0/0
Was First Aid provided to Injured Person?
*
Yes
No
Refused
Initial Treatment:
*
No treatment required.
Ice
Wheelchair
CPR
Strapping or Bandage
Follow up Action:
*
No treatment required.
Medical Practitioner
Hosptital
Ambulance
Other
Injured Person was treated by:
*
Ambulance / First Responder
Lifeguard
Games Controllers
Witness(es) (If none, write "None"):
*
Phone Number of Witness:
Back
Next
Submit
Was Next of Kin, Parnet or Qardian Contacted (if yes name and phone number):
*
Any other relevant information, please provide here.
Should be Empty: