Accident Report
*This form must be submitted to the Club Sports Office, Fitness Center, Room 201, within 48 hours of the accident **Please complete in detail and use back side of form if necessary
Name
Sex
Address
Phone Date of Birth
City/State/Zip Please Circle One:
Student
Faculty/Staff
Spectator
Sport Injured In:
M
F
Other (specify):
Time of Injury
Date of Injury: Venue Injury Occurred At Please Circle One:
PRACTICE
GAME vs.
LOCATION OF INJURY: Please Check ALL Impacted Areas
□ ABDOMEN □ ANKLE □ ARM □ BACK □ CHEST □ EAR
□ EYE □ FACE □ FINGER □ FOOT □ GROIN □ HAND
□ HIP □ JAW □ KNEE □ MOUTH □ NECK □ NOSE
□ SHIN □ TEETH □ THIGH □ TOE □ TONGUE □ OTHER
SIDE OF BODY Check applicable box(es)
LEFT RIGHT N/A
Describe how the injury occurred and what actions were taken. (Write on back if needed)
PREPARED BY WITNESS
DATE DATE
FOLLOW-UP INFORMATION REVIEWED BY
DATE