ACCIDENT/INJURY REPORT

PERSONAL DETAILS:
Name:__________________________ Age:____________ DOB:_____/_____/_____
Address:_______________________________________________________________________
Parent/Guardian Name:___________________________________________________________
Team:__________________________ Coach:_____________________________________
Date of Report:______/______/______ Completed By: _______________________________

ACCIDENT/INCIDENT DETAILS:
Date:_____/_____/_____ Time:____________ Date Reported: _____/_____/_____
Location:_________________________________ Witness:_________________________
Reported to Whom:____________________________________________________________

Full Accident/Incident Details:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________________

Injury-Nature of Injury:
____ Contusion ____Burn ____ Dislocation ____ Amputation
____ Laceration/Open Wound ____ Superficial Injury ____ Foreign Body ____ Internal Injury
____ Concussion ____ Sprain/Strain ____ Fracture ____ Dermatitis

Location of Injury:
_____ Head/Face _____ Eye ______ Internal Organs
_____ Hand/Finger _____ Shoulder/Arms ______ Trunk (other than back)
_____ Hip/Leg _____ Foot/Toes ______ Back
_____ Other (state)

Results of Accident:
Was first aid rendered?_____ Yes _____ No If yes, by whom/date/time:____________________________
Describe first aid:________________________________________________________________________
Was medical attention needed/received? _____ Yes _____No
If yes, describe medical attention. If unknown, please state: ______________________________________
______________________________________________________________________________________

EMERGENCY CONTACT INFORMATION:

Person Contacted/Relationship:____________________________________________________________
Address:________________________________________________ Phone: _________________
Contacted by:_________________________ Date: ____/____/____ Time: ___________________

Report received by OCSC on: ______/_____/_____

Received by:________________________________