Venture Athletics Incident Report
Accident Date
*
Time
*
Name of Injured Athlete
*
Name of Parent/Guardian
*
Parent/Guardian's Phone Number:
*
Address
Street Address
*
City
State
1. CLASSIFICATION OF INJURED (check one)
*
Athlete
Staff
Guest
Other
2. IS THE INJURY MINOR?
*
Yes
No
3. ACCIDENT LOCATION (check one)
*
Gym
Lobby
Other
ACCIDENT LOCATION (if other, specify here)
4. ACTIVITY AREA OF ACCIDENT (check one)
*
Spring Floor
Dead Mat
Tumble Track
Dance Floor
Other
ACTIVITY AREA OF ACCIDENT (if other, specify here)
5. CAUSE OF ACCIDENT (check one)
*
Collision with obstacle (wall, post, etc)
Collision with person
Fall
Hit by projectile
Previous injury
Sudden tuen, twist, or stop
Other
CAUSE OF ACCIDENT (if other, specify here):
6. TYPE OF INJURY SUSPECTED IF KNOWN (check any that apply)
*
Bruise
Concussion
Dislocation
Fracture
Laceration
Sprain/Strain
Other
TYPE OF INJURY SUSPECTED IF KNOWN (if other, specify here)
7. BODY PART INJURED
Abdomen
Right
Left
Ankle
Right
Left
Back
Right
Left
Elbow
Right
Left
Eyes
Right
Left
Face
Right
Left
Fingers
Right
Left
Foot
Right
Left
Hand
Right
Left
Hip
Right
Left
Head
Right
Left
Knee
Right
Left
Lower Arm
Right
Left
Lower Leg
Right
Left
Neck
Right
Left
Shoulder
Right
Left
Thumb
Right
Left
Toes
Right
Left
Trunk
Right
Left
Upper Arm
Right
Left
Upper Leg
Right
Left
Wrist
Right
Left
8. BLOOD EXPOSURE (check one)
*
Yes
No
9. FIRST AID RENDERED (check all that apply)
*
CPR/Rescue Breathing
Gave Ice
Kept Immobile
Stopped Bleeding
Washed Wound
Victim of Self-care
None Rendered
Other
FIRST AID RENDERED (if other, specify here)
10. FURTHER CARE - DISPOSITION (check one)
*
Ambulance to hospital
Security to hospital
Self/Friend to hospital
Went to Health Services
Went home on own
Friend to home
Left area, no info
Continued Activity
Coach Name
*
Signature of Report Filer: (Signature or Initials)
*
Clear
Date Sent
*
Send Form
