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 OCCURRENCE Section A: Person Injured Person Injured Player Official Coach Other Name First Last Date of Injury Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Afghanistan Albania Algeria American Samoa Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faroe Islands Fiji Finland France French Polynesia Gabon Gambia Georgia Germany Ghana Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Sudan, South Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Country Email (1st) Witness Name First Last (1st) Contact Number (2nd) Witness Name First Last (2nd) Contact Number Location of Injury Outdoor Rink Indoor Rink Bleachers Locker Room Outside of Venue Name of Arena Name of Team/Organization City Form Completed By: Contact Number: Age Category Please Select One U6 U7 U8 U9 U10 U12 U14 U16 U19 18+ 35+ Level AA A BB B CC C Dev. Rec. House Leag. Provincial Regional Type of Activity Game Recreation Tryout Practice Injury Occurred During Pre Season Regular Season Post Season Playoffs Time : HH MM AM PM Period of Play First Second PLEASE COMPLETE SECTION 'A' ABOVE IN FULL AND AS MUCH OF SECTION 'B' BELOW AS POSSIBLE Section B: Details Of Injury Body Part(s) Injured - Front CTRL or ⌘ Click to select all that apply Face R. Shoulder L. Shoulder Chest Abdomen Groin R. Hand L. Hand R. Knee L. Knee R. Ankle L. Ankle Body Part(s) Injured - Back CTRL or ⌘ Click to select all that apply Head Neck/Spine L. Elbow R. Elbow Lower Back Buttocks L. Hamstring R. Hamstring L. Calf R. Calf L. Foot R. Foot Incident Details p1 Please indicate in the box below what caused the injury and whether it could have been avoided, i.e. equipment failure (make/model). Incident Details p2 Please indicate where on the ice the incident occurred. Describe as best as possible. Subject Involved Male Female Weight (lbs) Height (inch) Year of Birth Nature of Injury Fracture Laceration Sprain/Strain Head Injury Dislocation Skin Injury Recurring Injury Other (Specify Below) Other If injury above is 'Other', please specify details here Injury Type Contact Non Contact Symptoms 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 911 Other If symptoms above is 'Other', please specify details here Care Trainer Hospital Care EMS Family Physician Initial Treatment RICE (Rest, Immobilize, Cold, Elevate) CPR Stretching Manual Therapy Dressing Wrapping/Taping Sling/Splint None Was Injured Party Wearing Protective Equipment? Yes No If not, why? Has the injured party filed an insurance claim? Yes No Anticipated Injury Time Loss: 0 Days 1-5 Days 5-10 Days 10+ Days Signature Please type your name when using this online form Date 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.
