Safety Guidelines for Secondary Interschool Athletics in Alberta
Safety Guidelines for Secondary Interschool Athletics in Alberta
Safety Guidelines for Secondary Interschool Athletics in Alberta
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APPENDIX C - Sample Accident/Injury Report<strong>in</strong>g Form<br />
The <strong>in</strong><strong>for</strong>mation collected below will be used <strong>for</strong> the purposes of atta<strong>in</strong><strong>in</strong>g particulars about the<br />
accident/<strong>in</strong>jury. All of the <strong>in</strong><strong>for</strong>mation collected will be protected and used <strong>in</strong> compliance with the<br />
Freedom of In<strong>for</strong>mation and Protection of Privacy (FOIPP) Act.<br />
Name of Individual Complet<strong>in</strong>g this Form: ________________________________________________<br />
Phone: _____________________________________________________________________________<br />
Name of Injured: ____________________________________________________________________<br />
School: ____________________________________________________________________________<br />
Date Form Completed: _______________________________________________________________<br />
Personal Health # (Optional):___________________________________________________________<br />
Student I.D. #:_______________________________________________________________________<br />
Sex:___________________ Age: ___________ Gender: ______________<br />
Date of Incident:_____________________________________________________<br />
Time of Incident:______________________________________________________________<br />
Indicate the one (or more) most appropriate statement(s) from each of the follow<strong>in</strong>g sections (with an<br />
‘x’):<br />
1. Body Region(s) Injured:<br />
If applicable, please <strong>in</strong>dicate:<br />
Right or Left<br />
Neck Hand Gro<strong>in</strong> Head Shoulder<br />
F<strong>in</strong>ger Thigh Face Upper Arm Chest<br />
Knee Nose Elbow Abdomen Lower Leg<br />
Eye Forearm Back Ankle Ear<br />
Wrist Buttocks Foot Teeth<br />
Other:_________________________________________________________________<br />
Please provide specific relevant details of the <strong>in</strong>jury: ______________________________________<br />
_________________________________________________________________________________<br />
2. Type of Injury:<br />
Abrasion/Scrape<br />
Burn<br />
Bone Bruise – swell<strong>in</strong>g and/or discoloration of bony area<br />
Concussion – temporary loss of orientation or unconsciousness<br />
Discoloration/separation – de<strong>for</strong>mity of a jo<strong>in</strong>t<br />
Fracture<br />
Laceration/<strong>in</strong>cision/puncture – an open wound<br />
Muscle stra<strong>in</strong> (pull or tear) – due to use rather than blow<br />
Nose bleed<br />
Spra<strong>in</strong> – twist<strong>in</strong>g or mov<strong>in</strong>g of a jo<strong>in</strong>t beyond normal range<br />
Teeth – loosened or broken<br />
Other:__________________________________________________<br />
Cont<strong>in</strong>ued on next page<br />
<strong>Safety</strong> <strong>Guidel<strong>in</strong>es</strong> <strong>for</strong> <strong>Secondary</strong> <strong>Interschool</strong> <strong>Athletics</strong> <strong>in</strong> <strong>Alberta</strong> - February 2012 73
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