Injury Reporting Form
PLAYER DETAILS
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Email Address
*
Parent/guardian email if a junior
Phone Number
*
Parent/guardian phone number if a junior
Format: (000) 000-0000.
Club/team player plays for
INJURY DETAILS
Date and Time of Incident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location Injury Occurred
*
Karratha Leisureplex
Other
When did the injury occur
*
Training
Scheduled game
Warm-Up
Other
How did the injury happen?
*
People Involved or Witnesses (names and contact info, if known)
What part of the body was injured?
*
Head / Face
Neck
Shoulder
Arm
Elbow
Wrist
Hand / Fingers
Back
Hip
Groin
Knee
Ankle
Foot
Other
Which side
*
Left
Right
Both
Not Applicable
Type of injury (if known)
Sprain
Strain
Fracture
Dislocation
Bruise / Contusion
Cut / Abrasion
Concussion symptons
Other
Injury Severity. Did the player stop participating?
*
No, continued playing
Yes, stopped immediately
Returned after treatment
Was First Aid provided
*
Yes
No
If yes, what first aid was provided?
Did the player experience any of the following? (Select all that apply)
*
Loss of consciousness
Dizziness
Confusion
Headache
Nausea
Difficulty moving the injured area
Swelling
Severe pain
Other
Has the player seen a medical professional?
*
Yes
No
Has the player been cleared to return to basketball? Please note, KBA may ask for proof for medical clearance in order to return.
*
Yes
No
Awaiting medical clearance
Acknowledgment (Parent / Guardian acknowledgement if the injured player is under 18 years old)
*
I confirm the information provided is accurate.
I understand that Karratha Basketball Association may follow up regarding this injury and player welfare.
Parent / Guardian name (if player under 18 years old)
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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