INJURY REPORT FORM
INJURY REPORT FORM
HILLS BASKETBALL ASSOCIATION INJURY REPORT FORM
DETAILS OF INJURED PERSON
Details of the Injured Participant
Details of the Injured Participant
*
First
Last
Date of Birth
Date of Birth
/
DD
/
MM
YYYY
Gender
*
Gender
Female
Male
DETAILS OF INJURY
This is the description of your section break.
Date of injury:
Date of injury:
*
/
DD
/
MM
YYYY
Competition/Event
*
Venue
*
Hills Basketball Stadium
Bernie Mullane Sports Complex
Dural Recreation Centre
Court
Other Area
WHAT SIDE OF THE BODY WAS INJURED?
WHAT SIDE OF THE BODY WAS INJURED?
Left
Right
Not Applicable
WHAT PART OF THE BODY WAS INJURED?
*
WHAT PART OF THE BODY WAS INJURED?
Abdominal
Achilles
Ankle
Calf Muscle
Chin
Back
Buttocks
Elbow
Eyelid
Face
Fingers
Foot
Hand
Knee
Head
Lips
Leg
Neck
Shoulder
Tailbone
Thumbs
Wrist
Chest
Collarbone
Ears
Groin
Hips
Mouth
Nose
Throat
Teeth
Other
Other
CAUSE OF INJURY:
*
CAUSE OF INJURY:
Basketball (Hit/Thrown/Catching)
Collision/Contact with player/referee
Fall/Stumble
Jumping/Landing to shoot/defend/rebound
Running
Slip - due to slippery floor
Struck by ball or object
Collision with a fixed object
Change of direction
Gradual onset, no cause identified
Landed on another players foot and turned ankle
Slip/trip
Struck by another player
Temperature related
Other
Other
TYPE OF INJURY:
*
TYPE OF INJURY:
Abrasion/graze
Broken Bone(s)
Bruise/Contusion
Concussion
Hypertension
Fracture (including suspected)
Open wound/laceration/cut
Respiratory Problem
Strain e.g musle tear
Blisters
Broken/Chipped Tooth/Teeth
Cardiac problem
Dislocation
Inflammation/swelling
Loss of consciousness
Overuse injury
Sprain e.g ligament tear
Unspecified medical condition
Other
Other
INITIAL TREATMENT REQUIRED:
*
INITIAL TREATMENT REQUIRED:
Breathing slowly
Compression/Bandage
Dressing
EpiPen
Fluids - e.g water/electrolytes
Massage/Stretch
Sling/Splint
Waited for ambulance
CPR
Declined any treatment
Elevated
Flushed with water
Ice/Ricer
Strapping/Tapping
None required
Other
Other
DID THE INJURED PERSON GO TO HOSPITAL?
*
DID THE INJURED PERSON GO TO HOSPITAL?
Yes - by car
Yes - by ambulance
No
Unknown
WITNESS INFORMATION
Did anyone witness this injury?
Did anyone witness this injury?
First
Last
Phone Number
Additional notes (if required)
DETAILS OF PERSON COMPLETING FORM:
This is the description of your section break.
Form completed by:
Form completed by:
*
First
Last
Draw your signature into the box below.
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.