Athletic Accident Injury Report This information below will be sent to the Athletic Director, AD Secretary and HS Nurse with a copy sent to you. Please fill in as much information as you can. All information will be kept confidential. PhoneThis field is for validation purposes and should be left unchanged.Your Name* First Last Your Email* Injured Student's Name* First Last Injured's District/School ID NumberGrade*Select OneK123456789101112Injured's Date of Birth* Date of injury* Time of injury* : Hours Minutes AM PM AM/PM Sport or activity performed*Select OneFootballSoccerCross CountryVolleyballTennisCheeringBasketballWrestlingWinter TrackBowlingSwimmingBaseballSoftballSpring TrackIntramural SportsPhys Ed ClassSummer SportsPracticeOtherLocation or building where injury occurred*Select OneK CenterLincolnWashingtonPierrepontUnionRHSMemorial FieldPool (in RHS)Not In Rutherford / Other TownOther ActivityOther locationRoom or gym numberTeacher(s) / Coach(es) / Employee(s) responsible for injured at time of injury*Contacted Parent / Guardian / Emergency Contact*Select OneYesNoContacted Emergency Services*Select OneYesNoDid injured leave the site immediately after injury?*Select OneYesNoIf left, with whom?Select OneParent(s) / Guardian(s)EMSOtherOther Responsible partyTransportation methodInjury Site LEFT*Select OneAnteriorInferiorLateralMedialPosteriorSuperiorMultisiteNot ApplicableInjury Site RIGHT*Select OneAnteriorInferiorLateralMedialPosteriorSuperiorMultisiteNot ApplicableAffected Body Part*Select OneAbdomenAchillesAnkleC-SpineCoccyxEarElbowEyeHand Digit 1Hand Digit 2Hand Digit 3Hand Digit 4Hand Digit 5HeelHipFaceFoot Digit 1Foot Digit 2Foot Digit 3Foot Digit 4Foot Digit 5ForearmForefootHeadKneeLower LegLumbar SpineMouthNoseRibsSacrumShoulderSternumT-SpineThighUpper ArmWristStructure*Select OneBoneBursaeCartilageCompartmentLigamentMuscleTendonOtherNature of injury*Select OneBursitisConcussionContusionDislocationFractureOtherSprainStrainTendonitisDisposition of injury*Select OneNo ParticipationLimited ParticipationFull ParticipationReferral*Select OneDentalMedicalOrthopedicOtherPalpationDeformityRange of MotionDiscolorationSwellingStrengthSpecial TestsHow the injury occurred*Treatment administered*Assessment*