Home About Meet the Staff Mission, Vision and Values Student Employment Student Recreation Advisory Council Contact Us Memberships/Access Facilities Student Recreation and Wellness Center Golf Simulator Facility Policies Facility Use & Rental Requests Rec Plex Fresh on the Fox Outdoor Facilities Albee Hall and Pool Kolf Sports Center Programs Group Exercise Health Promotion Intramural Sports Outdoor Adventure Center Bike and Ski Shop Climbing Wall Rentals Trips and Clinics Personal and Small Group Training Sport Clubs Strength & Conditioning Special Events Shamrock Shuffle Programs Intramural Sports Group Exercise Outdoor Adventures Personal and Small Group Training Strength & Conditioning Sport Clubs Special Events Sport Club Injury Report Form Sport Clubs Injury Report All accidents are to be reported immediately. Please fill in ALL information pertaining to the incident. Date of Injury* MM slash DD slash YYYY Time of Injury* : Hours Minutes AM PM AM/PM Name of party injured* First Last Sex of Injured* Female Male Local Address of Injured* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number of Injured*UW Oshkosh Affiliation of Injured* Student Faculty/Staff Guest If Student, Titan ID Number of Injured Please describe the nature of the suspected injury*Ex. bleeding to the upper arm Location*Please specify the exact location (i.e. Room Number, Activity Area, Field/Court Number) of the accident and the conditions in which the accident occurred.How did the injury occur?*Describe fully the events, actions, and conditions which contributed to the injury.What action was taken?*Precisely explain exactly what action was taken.Care of injured transferred toname, position, title Police called* Yes No If yes, what time did the police arrive? Ambulance called* Yes No If yes, please give time called and arrived in "other"If yes, what time did the ambulance arrive? Sent to Health Services* Yes No Sent to hospital/clinic* Yes No If sent to hospital/clinic, which one? Refusal of treatment* Yes No Refusal of transport* Yes No Witness #1 name, address, phone*Witness #2 name, address, phoneWitness #3 name, address, phoneAny additional or follow-up remarks? Δ