Injury Report Form (Whitby Minor Hockey)

Basic Information

Player Name ^*

Required

Date Of Injury ^*

Required

Time Of Injury ^*

Required

Location of Injury^*

Required

Team and Division (U10 AAA, U5 Team 1) ^*

Required

Game or Practice^*

GamePractice

Required

Injury Details

Type of Injury^*

Required

(Sprain, Fracture, Concussion, Laceration, etc.)

Body Part Affected^*

Required

Severity of Injury ^*

Mild
Moderate
Severe

Required

(Mild, Moderate, Severe)

Was the Player Concious?^*

YesNo

Required

Was there any bleeding or swelling?^*

Bleeding
Swelling
No

Required

Visible Symptoms^*

Required

(Dizziness, Nausea, Disorientation/Confusion, Pain)

Incident Description

Describe how the injury occured ^*

Required

(Specific event, Contact with player/equipment)

Immediate Response

Who provided initial care? ^*

Required

(Name and Role)

Was the player removed from play?^*

Required

First Aid Administered: ^*

Required

what was done immediately on-site?

Was 911 called or emergency services involved?^*

YesNo

Required

Follow-Up Care

Was the player sent to a hospital or clinic?^*

YesNo

Required

Is any further treatment recommended?^*

Required

(X-Ray, MRI, Concussion Protocol, etc.)

Was a Hockey Canada Injury Report completed^*

YesNo

Required

Additional Notes

Please add any relevant observations or remarks from the coach, officials, or medical personnel

Injury Report Form (Whitby Minor Hockey)

OMHA Digital Network

Basic Information

Injury Details

Incident Description

Immediate Response

Follow-Up Care

Additional Notes

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