Howell Soccer Club Accident/Injury Report

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Please report all injuries within 24 hours of the occurrence. This includes injuries to all spectators, players, or coaches during practices and games. If the incident requires a call to 911, please complete this form and report it immediately to president@howellsoccerclub.com.

Date of Incident *

YYYY

Time of Incident *

Time

Activity *

Location of Incident *

Injured's Name *

Gender *

Male

Female

Prefer not to say

Other:

Injured's Age *

Division *

What is the Nature of the Injury? *

(Ex. Hurt Right Leg, Head Injury, Rolled Left Ankle) - DO NOT DIAGNOSE; Do not use words such as "Fractured" or "Broken". Please give us a direction (left or right) and body part (arm, wrist, leg, ankle, knee, head, etc.)

Describe the Incident *

Please describe what happened leading up to the incident.

What Action was Taken and by Whom? *

Tell us what treatment was given at the field. (Ice, Ambulance Called, Someone Drove Player to Doctor/ER, ETC.)

Was an Ambulance Called? *

Remember to email president@howellsoccerclub.com immediately if an ambulance was called.

Yes

Did the Participant Return to the Activity? *

Yes

Yes, but later left the activity again due to the same injury.

Submitter's Name *

Submitter's Role *

Submitter's Email *

Submitter's Phone Number *

Submit

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