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Injury Report
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* Indicates required question
Time & Place of Accident/Incident
Date
*
MM
/
DD
/
YYYY
Time
*
Time
:
AM
PM
Location
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Injured Person
Name
*
Your answer
Age
*
Your answer
Address
*
Your answer
Phone
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Club Sport Team
*
Choose
Equestrian
Maasti
Men's Basketball
Men's Soccer
Swimming
Tennis
Ultimate
Women's Soccer
Women's Volleyball
Nature of Injury
*
Your answer
Did the victim refuse medical attention by Athletic Trainer/Staff?
*
Yes
No
Was EMS Called?
*
Yes
No
Witness
Name
*
Your answer
Phone Number
*
Your answer
Address
*
Your answer
Describe Incident Facts in Detail
To the best of your ability, please describe the facts of the incident in complete detail.
*
Your answer
Signature
*
Your answer
Date
*
MM
/
DD
/
YYYY
Report Taken By
*
Your answer
Date
*
MM
/
DD
/
YYYY
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