Injury Report Form Please enable JavaScript in your browser to complete this form.Details of Injured PersonName *FirstLastDate of Birth *Gender *MaleFemaleDetails of InjuryDate of Injury *Location *Court 1Court 2OtherWhat part of the body was injured? *AbdominalAchilles – LeftAchilles – RightArm – LeftArm – RightAnkle – LeftAnkle – RightCalf Muscle – LeftCalf Muscle – RightChestChinCollar BoneBackBody – Multiple points of injuryButtocksEarsElbow – LeftElbow – RightEyelidGroinFaceFoot/ FeetFinger(s)Foot – LeftFoot – RightGroinHand – LeftHand – RightKnee – LeftKnee – RightHeadHipsLipsLeg – LeftLeg – RightMouthNeckNoseShoulder – LeftShoulder – RightTailboneThroatThumbTeethWrist – LeftWrist – RightCause of Injury *Basketball (Hit/Thrown/Catching)Collision/Contact with player/refereeFall/StumbleJumping/Landing to shoot/defend/reboundRunningSlip – due to slippery floorStruck by ball or objectCollision with a fixed objectChange of directionGradual onset, no cause identifiedLanded on another players foot and turned ankleSlip/tripStruck by another playerTemperature relatedOtherType of Injury *Abrasion/grazeBroken Bone(s)Bruise/ContusionConcussionHypertensionFracture (including suspected)Open wound/laceration/cutRespiratory ProblemStrain e.g muscle tearBlistersBroken/Chipped Tooth/TeethCardiac problemDislocationInflammation/swellingLoss of consciousnessOveruse injurySprain e.g ligament tearUnspecified medical conditionOtherInitial Treatment Required *Breathing slowlyCompression/BandageDressingEpiPenFluids – e.g water/electrolytesMassage/StretchSling/SplintWaited for ambulanceCPRDeclined any treatmentElevatedFlushed with waterIce/RicerStrapping/TappingNone requiredOtherDid the injured person go to hospital? *Yes – by carYes – by ambulanceNoUnknownWitness InformationDid anyone witness this injury?FirstLastPhoneAdditional notes Phone Type What Details of person completing formPerson completing form *FirstLastPhone *Signature Clear Signature Submit