Club Sports Injury Report

This form will be electronically sent to Recreation and Wellness Administration. Complete to the best of your ability. Persons included in this report may be contacted later for additional details or follow-up.

* Name of injured person:

* Injured person's N#:

* Age of injured person:

* Injured person category:

* Full address of injured person:

* Phone number of injured person:

* Date/time of incident:

* List the Club Sport activity during which the incident occurred:

* Was this activity a game or practice:

Game
Practice

* Where did the incident occur:

* Describe the incident (be as detailed as possible and note the location of the injury):

* Describe the care provided (ex: ice or first-aid):

* Who provided care (name and N#):

* Was injured person advised to seek professional medical attention:

* Did the injured person acknowledge advised professional medical attention:

* 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.

* Name of Witness #1:

* Witness #1 affiliation:

* Witness #1 phone number:

* Witness #1 statement:

Name of Witness #2:

Witness #2 affiliation:

Witness #2 phone number:

Witness #2 statement:

* Name and N# of Club Sports participant submitting this report:

* Email address:

* Today's date: