Staff/Field Supervisor Accident/Incident Report


Person Completing Report

Name

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Title

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Street Address

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City, State, Zip

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Home Phone

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Day Phone

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E-Mail

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Accident/Incident Information

Date

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Time

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Type of Incident
 
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Event

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Event Date(s)

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Location Address

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Specific Location

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Bodily Injury Report

Name of Injured Person

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Birth Date

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Gender
 
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Address

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City, State, Zip

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Parent/Guardian Name

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Home Phone

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Day Phone

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E-Mail

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Additional Contact Information

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Part of Body Injured

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Describe Injury

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Brief Summary of Incident

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Was First Aid Administered?
 
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Who Administered First Aid?

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Describe First Aid Given

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Were Paramedics Called?
 
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Paramedic Service Offered?
 
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Were Policed Called?
 
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Police Department

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Officer

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Police Report Number

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Were Parents/Guardians Notified?
 
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By Whom?

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Notifier's Day Phone

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Name of Parents/Relative Contacted?

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Relationship

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Home Phone

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Day Phone

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E-Mail

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Complete Witness Information
(Another Coach/Staff Member of RSLFC)

Name of Witness

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Street Address

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City, State, Zip

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Home Phone

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Day Phone

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E-Mail

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Relationship to Injured Party?

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Relationship to Injured Party?
 
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Other

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Did Witness Make an official statement?
 
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If yes, describe

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Player Disposition/Update

Did injured player continue to practice/game?
 
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Did injured player leave before the even was over with parent/guardian?
 
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Has there been a follow-up phone call to the parent/guardian of the injured player by a responsible staff member?
 
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If yes, please describe the conversation

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Since injury/incident, has the injured player reported to a practice/game/event?
 
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