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Injury Report Form
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Full Name
Sport
Date of injury
Date of injury
Date of injury
Contact Phone
Location
What field or gym did this occur?
Address1
City
State
Zip
How did the injury occur?
Nature and extent of the injury?
Was the athlete transported?
Home
Hospital
Other
N/A
Who transported the athlete?
Was first aid given?
Yes
No
If yes, explain:
Was protective equipment worn?
Condition of playing surface?
Witnesses
Please list all witnesses and contact numbers.
Reported by
Name
Email
Phone
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