Sport Clubs Injury Report Form - Student Recreation

Date of Injury*

Time of Injury*

: HH

MM

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 to

name, 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, phone

Witness #3 name, address, phone

Any additional or follow-up remarks?

Sport Club Injury Report Form

Sport Clubs Injury Report