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Student Activities
Club Listing
Club Accident Report
Club Accident Report
*
= required field
REPORTING PARTY INFORMATION
Name
*
First
Last
Email Address
*
Phone Number
*
###
###
####
Club / Organization
*
Was reporting party a witness to the injury?
*
Yes
No
INJURED PARTY INFORMATION
Name
*
First
Last
Role
*
Student
Coach/Advisor
Other (explain)
If other please specify:
Email Address
*
Phone Number
*
###
###
####
Details of accident / incident
Date of injury
*
MM
DD
YYYY
Time of Injury
*
Where did the injury occur (geographic location – be specific)
*
How did the injury occur (be specific)
*
Part of body injured (be specific - identify which body part(s), left, right, top, bottom, etc.)
*
Describe extent of the injury
*
Was medical treatment provided?
*
Yes
No
If yes describe treatment
Was injured party transported to and/or hospitalized?
*
Yes
No
If yes, where?
Is this condition:
*
an acute injury
Chronic/Overuse Condition
Has the injured party injured the same body part in the past?
*
Yes
No
Don't Know
Sport Type
*
Intramurals
Practice
Game
Other (describe)
If other, describe
Names of witnesses to the injury:
Who was supervising the activity at the time of the injury/incident?
*
Reminder: all injured players are not allowed to return to practice or a game WITHOUT WRITTEN CLEARANCE FROM SIENA COLLEGE HEALTH SERVICES.