Incident Report

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					                                            USF Sports Club Incident Report
                                                    GENERAL INFORMATION
 PROGRAM AREA: FACILITY FITNESS                    IM       ORC      CAMPS AQUATICS Date: ___/___/___    Time:______ AM / PM
   SPORT CLUBS           ROPES COURSE             RFP     Other:_________________________________________________________
 SUBJECT'S NAME:                                                                                           AGE:         GENDER: M         F
 STATUS (circle one) : STUDENT   / FACULTY/STAFF / GUEST / Other:___________________   ID# (UID/SS#/DL#):__________________________
 Local Address:
 Local Phone:
 If under 18, name and phone # of parent/legal guardian:
                                                    LOCATION INFORMATION
 BUILDING/AREA OF ACCIDENT (circle one):
 Campus Rec           RFP      Pool       IM Fields Maintenance Other:______________________
 Specific Location (room #/court #/machine/etc):
                              OUTDOOR ONLY: WEATHER CONDITIONS (IM fields/RFP/Maintenance)
 TEMPERATURE ( 0F ):                           WIND CONDITION / SPEED:
 PRECIPITATION TYPE / SUNSHINE:
 Other (please describe) :
                                                    INCIDENT INFORMATION
                                                INCIDENT TYPE: (check those that apply)
      INJURY (required medical attention/first-aid - SEE BELOW)             ILLNESS (required medical attention)
      BEHAVIORAL (significant disruptive behavior)                          SITE (facility damage, equipment, vehicle, etc.)
      SUSPECTED ABUSE                                                       UNWANTED VISITOR
      NEAR MISS (any event having serious incident potential)               Other:_____________________________________________
                                                         DETAILS OF INJURY
 Part of body injured (circle all that apply):              LEFT           RIGHT           N/A
    Head        Face         Ear      Mouth        Teeth       Eye        Nose      Shoulder    Neck        Arm        Elbow
    Wrist       Hand       Finger     Torso        Back        Ribs        Hip        Groin     Leg        Knee        Ankle
    Foot         Toe     Other:____________________________________________________________________________________
 Visible symptoms of injury (circle all that apply):
Strain/Sprain      Dislocation       Seizure        Broken Bone(s)         Laceration/Cut       Severe Bleeding   Contusion/Bruise
 Head Injury      Airway/trouble breathing        Cardiac       Sudden Illness       Unresponsiveness Other:______________________
 Description of how injury occurred (circle events leading up to the injury):
       Collision with obstacle             Collision with person           Hit by projectile      Pre-existing      Non-contact
   Equipment related      Sudden stop or turn           Boating             Swim Rescue               Fall           Unknown
 Other (please describe):_________________________________________________________________________________________
        BELOW, DESCRIBE THE DETAILS OF THE INCIDENT AS YOU UNDERSTAND THEM. STATE ONLY THE FACTS CLEARLY AND CONCISELY.
                                    USE ADDITIONAL SHEETS OF PAPER TO DESCRIBE THE INCIDENT A




 Subject's Name:____________________________________                                                                   Date:___/___/___
                                                   IMMEDIATE ACTION TAKEN
 First Aid rendered (circle all that apply):           Name of care giver:__________________ Title:_____________________
       Applied ice       Stopped Bleeding         Immobilized     Elevated     Washed wound           Subject self care
   Abdominal thrusts     Bandage/pressure      None Other:______________________________________________
 Describe in greater detail (attach extra paper as needed):




 Further Care (circle all that apply):
      Ambulance to hospital         Went home on own        Returned to activity  Friend took home     Self/friend to Health Center
      Self/friend to hospital          Declined Care         Left area no info   Other:______________________________________
                                               INVOLVEMENT INFORMATION
WITNESS NAME:                                                                    ROLE (pick from below) :
WITNESS NAME:                                                                    ROLE (pick from below) :
WITNESS NAME:                                                                    ROLE (pick from below) :
            **ROLE: CAMPUS REC EMPLOYEE, STUDENT, FACULTY/STAFF, GUEST, FRIEND, CAMP PARTICIPANT, OTHER (SPECIFY)**
                                                            FOLLOW-UP
STATUS OF INJURED PERSON:
Date: ___ / ___ / ___             Time:___________                 Caller Signature:_____________________________________
    The injured person is fine. No complications.                      Unknown. Unable to contact the injured person.
    The injury was serious enough to warrant additional medical attention. The injury was diagnosed as ___________________
                                                      ADDITIONAL NOTES




          I, the injured party, herein certify the information set forth above is true and correct to the best of my knowledge.

Injured Signature:_______________________________________________                                       Date: ___ /___ /___

Signature of Parent/Legal Guardian (if minor):_________________________________ Date: ___ /___/___


Form Completed By (print):________________________ Signature:________________________ Date: ___/___/___

Area Coordinator signature:_________________________________________                                        Date: ___/___/___

EAP Committee signature:__________________________________________                                          Date: ___/___/___