ACCIDENT/INCIDENT REPORT FORM

Date of incident: _______________ Time: ________ AM/PM

Location: ____________________________________________

Nature of Event: _______________________________________

Name of injured person:

Address:

Phone Number(s):

Date of birth: ________________            Male ______ Female _______

Grade ____________ School _______________________________________

Who was injured person? (circle one) Player Spectator Coach

Type of injury:

Details of incident and injury (use back of sheet if necessary): ______ _______ __________________________________________

Parent Present? Yes______No_____       Parent Notified? Yes______No______

Paramedics called to scene? Yes _____No _____

Who contacted fire rescue to scene? ________________________________________________

 Injury requires transport? Yes _____No _____

Name of physician/hospital:

Address:

Physician/hospital phone number: ____________________________________________________ __________________

Name and Signature of Person completing this report                      Date