RRHC Injury Report Form

Injury Report Form to report injury to RRHC Safety Director.

Player First Name*

Player Last Name*

Player's Parent/Guardian Email Address*

Player's Team*

Head Coach Full Name*

Player Position*

Date of Injury*

Time of Injury* Time of day the injury occurred

Rink / Location*

Injury Occurred During*

Opponent*

Cause of Injury*

Injury Description*

Did the Injury Occur in the final five minutes of play?*

Was a Penalty Called?*

Area of Body Injured*

Where on the Ice Did the Injury Occur?*

Coaches present*

Who requested assessment of injured player?*

What was the King Devick Result (if tested)?*

Were the parents given the Parent Info Packet, found in the front lobby?*

Was 911 called or did player go to the ER?*

Diagnosis (if known)*

Submitter's Name*

Additional Information*

Confirmation