Sports Injury Report Form This form is to be completed by a club official at the time of the injury and submitted to the Provincial Sport Organization at the end of the game. Step 1 of 2 50% SUBMIT COMPLETED FORM WITHIN 7 DAYS OF INJURY OCCURRENCESection A: Person InjuredPerson Injured Player Official Coach Other Name First Last Date of Injury Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email (1st) Witness Name First Last (1st) Contact Number(2nd) Witness Name First Last (2nd) Contact NumberLocation of InjuryOutdoor RinkIndoor RinkBleachersLocker RoomOutside of VenueName of ArenaName of Team/OrganizationCityForm Completed By:Contact Number:Age CategoryPlease Select OneU6U7U8U9U10U12U14U16U1918+35+LevelAAABBBCCCDev.Rec.House Leag.ProvincialRegionalType of ActivityGameRecreationTryoutPracticeInjury Occurred DuringPre SeasonRegular SeasonPost SeasonPlayoffsTime : HH MM AM PM Period of PlayFirstSecond PLEASE COMPLETE SECTION 'A' ABOVE IN FULL AND AS MUCH OF SECTION 'B' BELOW AS POSSIBLESection B: Details Of InjuryBody Part(s) Injured - FrontCTRL or ⌘ Click to select all that applyFaceR. ShoulderL. ShoulderChestAbdomenGroinR. HandL. HandR. KneeL. KneeR. AnkleL. AnkleBody Part(s) Injured - BackCTRL or ⌘ Click to select all that applyHeadNeck/SpineL. ElbowR. ElbowLower BackButtocksL. HamstringR. HamstringL. CalfR. CalfL. FootR. FootIncident Details p1Please indicate in the box below what caused the injury and whether it could have been avoided, i.e. equipment failure (make/model).Incident Details p2Please indicate where on the ice the incident occurred. Describe as best as possible.Subject InvolvedMaleFemaleWeight (lbs)Height (inch)Year of BirthNature of Injury Fracture Laceration Sprain/Strain Head Injury Dislocation Skin Injury Recurring Injury Other (Specify Below) OtherIf injury above is 'Other', please specify details hereInjury TypeContactNon ContactSymptoms Loss of Feeling Pain Dizziness Shortness of Breath Loss of Consciousness/Fainting* Other *All loss of consciousness or fainting requires IMMEDIATE medical follow-up - CALL 911OtherIf symptoms above is 'Other', please specify details hereCare Trainer Hospital Care EMS Family Physician If treated at hospital care, transported by: Parent Member of bench staff Ambulance Initial Treatment RICE (Rest, Immobilize, Cold, Elevate) CPR Stretching Manual Therapy Dressing Wrapping/Taping Sling/Splint None Was Injured Party Wearing Protective Equipment?YesNoIf not, why?Has the injured party filed an insurance claim?YesNoAnticipated Injury Time Loss:0 Days1-5 Days5-10 Days10+ DaysSignaturePlease type your name when using this online formDate of Injury Current Date ALL INFORMATION COLLECTED ON THIS FORM OF A PERSONAL NATURE IS STRICTLY CONFIDENTAL AND WILL NOT BE DISCLOSED TO A THIRD PARTY. Please forward completed form to Ontario Ringette Association by mail, email or fax as indicated above, within 7 DAYS of the injury occurrence.