Injury Report Form

Health & Safety
Injury Report Form
Reporting an Injury
Please use this form to document injuries that occur during an EYSA practice, game, tournament, or other EYSA activity. Complete the form as soon as reasonably possible following the incident and provide as much information as you can.
Important: This form is for incident documentation and does not replace appropriate first aid or emergency medical care. If an injury requires immediate medical attention, contact emergency services first.
COMPLETE THE INFORMATION BELOW
PARTICIPANT'S NAME
First name, last name
DATE OF INJURY
RadDatePicker
RadDatePicker
Open the calendar popup.
date injury occurred
TIME OF INJRY
time of injury
ACCIDENT LOCATION
location where injury occurred
FIELD/GYM NUMBER
BODY PART INJURED
note which body part was injured
TYPE OF INJURY
select type of injury here
FIRST AID GIVEN
select the type of first aid given
ACCIDENT TYPE
ACTION TAKEN
DESCRIBE ACCIDENT
Please describe how the accident happened.
WITNESS #1
First and last name of witness. Witness phone number.
REPORT SUBMITTED BY
Please enter your name
Referee Name
Cell Phone Number #1
Enter a number to receive text messages.
Cell Phone Number #2
Required Fields