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INJURY REPORT FORM
CLUB
YEAR
INJURED PERSON
Name_________________________________________________________________
Local Address__________________________________________________________
Harvard ID_______________________
Age_______Sex ______ Class: Fr________Soph______Jr.______Sr.______
School or Department____________________________________________________
ACCIDENT
Date & Time accident occurred ____________________________________________
Where accident occurred(name of field, building,etc.)___________________________
Club Practice_____Club Competition Home_____ Away_____
Other (Specify)_______________________________________________________________
Part of Body Injured__________________Nature of Injury_______________________
Estimate Minor_________Serious_________Critical__________Fatal__________
Details of accident (describe fully, events, actions, and conditions involved):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
EMERGENCY CARE
First Aid______________ Trainer______________Private ______________
Physician_______________________Hospital________________________________
Other(specify)__________________________________________________________
______________________________________________________________________
Given by (name and address)_______________________________________________________________
______________________________________________________________________
Procedure followed_______________________________________________________________
______________________________________________________________________
Report prepared by___________________________Date_______________________
