Sample Injury Report Form
AMERICAN UNIVERSITY
INTRAMURAL/CLUB SPORTS
INJURY REPORT
INJURED PERSON
Name_________________________ Local Address__________________________
AU ID_______________________ Phone
Age_______ Sex_______ Class: Fr___Soph____Jr___Sr___ Grad F/S______
INJURY
Date of Injury: _____/_____/____ Time of Injury: ____:____ (am/pm)
Place of Injury: ____________________
Nature of Suspected/Stated Injury/Illness (Please be detailed):_____________________________
______________________________________________________________________________
____________
Description of Incident (describe fully, events, actions, and conditions involved):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Witnesses Information (Name, Address, and Phone):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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