SPORTS INJURY REPORT FORM
Name
*
Address
*
Gender:
*
Please Select
Male
Female
Event
*
Please Select
Junior Domestic
Senior Domestic
SQJBC
Practice
Other
Venue
*
Team Name
Date of Injury
*
-
Month
-
Day
Year
Date
Time of Injury
*
Hour Minutes
AM
PM
AM/PM Option
Injured Person
*
Please Select
Player
Referee
Coach
Spectator
Explain how the incident occurred
NATURE OF INJURY/ILLNESS
*
Please Select
Bruise/Contusion
Cardiac problem
Cold/flu
Concussion
Dislocation/subluxation
Fracture (including suspected)
Inflammation/swelling
Loss of consciousness
Overuse Injury
Respiratory problem
Skin Injury e.g. grave/cut/blister
Sprain e.g. ligament tear
Strain e.g. muscle tear
Unspecified Medical condition
Other
ACTION TAKEN
*
None taken
CPR
Dressing
Immobilization
RICER
Sling/Splint
Strapping/Taping
Stretch/Exercises
Transport from field/court
Other
Signature of injured person
*
Signature of treating person
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