Injury report
Name __________________________________________________________________
Date __________________________ Age _____________________________________
Nature of appearance of injuries______________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Location of Incident _______________________________________________________
Check all that apply:
Bleeding___________ How long? _________________ How much?________________
First aid?___________ What was done?_______________________________________
Loss of consciousness.__________ For how long?_______________________________
Unable to respond ______________ For how long? ______________________________
Confusion ____________________ Poor balance _______________________________
Loss of motor control__________ Describe____________________________________
Loss of color_______ Sweating___ Shivering______ Felt cold to touch______________
Panic/stress_______ Dismissive _______ Calm_______ Ignore ______
What was the person doing? ________________________________________________
________________________________________________________________________
________________________________________________________________________
Was this person being supervised? ___________________________________________
Action. EMS_______ Guardian notified _____Transported to help__________________
See physician soon_____ Must be physician cleared to resume training _____________
Other emergency or medical information_______________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signed __________________________________ Date___________________________
Position ________________________________________________________________
Contact _________________________________________________________________
________________________________________________________________________
