Club Sports | Recreation Center

Address

Program/ Group

Club Sports Informal Rec Intramurals Instruction Program Outdoor Program Other (If Other than list)
Other:
Injury Information
Injury Type

First Aid Athletic
Date and Time of Injury*
/ Month / Day Year
at
: Hour Minutes
Treated

Trainer Rec Staff
Treated By:
Was injured party advised to seek further treatment?
Was victim advised to discontinue further activity?
Did victim discontinue further activity?
Was an ambulance recommended?
Was an ambulance called?
Did victim refuse treatment?
Did victim sign a refusal form?
Description of how the injury occurred:
Location where injury occurred
Detailed Location of Injury
Treatment Information
What care was provided and what action was taken?
Participant left facility by:
Other:
First Aid Rendered

Stopped Bleeding Washed Wound Bandage/Tape Ice Splint Kept Immobile Recovery Position CPR None Other (If Other than list)
Other:
Full Name of Employee
First Name Last Name
Department
Full Name of Witness
First Name Last Name
Witness Phone Number
- Area Code Phone Number
Full Name Of Person Filling Out Form*
First Name Last Name
E-mail Of Person Filling out Form*
Date
/ Month / Day Year
at
: Hour Minutes
Should be Empty:

Recreation Center