* Name of injured person: |
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* Injured person's N#: |
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* Age of injured person: |
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* Injured person category:
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* Full address of injured person: |
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* Phone number of injured person: |
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* Date/time of incident: |
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* List the Club Sport activity during which the incident occurred: |
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* Was this activity a game or practice: |
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* Where did the incident occur: |
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* Describe the incident (be as detailed as possible and note the location of the injury): |
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* Describe the care provided (ex: ice or first-aid): |
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* Who provided care (name and N#): |
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* Was injured person advised to seek professional medical attention: |
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* Did the injured person acknowledge advised professional medical attention: |
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* Was Campus Police notified: note: If Campus Police was notified, call the Student Wellness Complex at (904) 620-5212 to let the night manager know. |
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* Name of Witness #1: |
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* Witness #1 affiliation: |
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* Witness #1 phone number: |
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* Witness #1 statement: |
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Name of Witness #2: |
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Witness #2 affiliation: |
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Witness #2 phone number: |
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Witness #2 statement: |
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* Name and N# of Club Sports participant submitting this report: |
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* Email address: |
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* Today's date: |
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