Incident Report

Incident Report Form

(Following an injury or illness, this form must be submitted by the coach to the CSA secretary within 48 hours)

Date of report:

Date of incident:

Time of incident:

Personal Data - Injured Party

Incident Data

Location of incident:
Description of incident:
Was the injury sustained? Yes_____ No _____
If yes, describe the type of injury sustained:
Witnesses
Name:	Name:
Address:	Address:
Phone:	Phone:

Care Provided

Did the victim refuse medical attention by staff? Yes _____ No _____
Was care provided by staff? Yes _____ No _____	Who?
Describe in detail care provided:
Were universal precautions taken? Yes _____ No _____
Was EMS called? Yes _____ No _____
If yes, by whom?	Time EMS called:		Time EMS arrived:
Was the victim transported to an emergency facility? Yes _____ No _____
If yes, where?
If no, person returned to activity? Yes _____ No _____
If no, what was the referral action taken:
Victim's signature: (Parent's/Guardian's if victim is a minor)		Date:

Facility Data

Facility (i.e. HPP, ...):

Weather conditions at time of incident:

Playing surface conditions at time of incident:

Report Prepared by:

Name (please print):

Position:

Signature: