Date of Report
*
MM
DD
YYYY
Time of Report
*
Hour
Minute
Second
AM
PM
Reporter's Name
*
First Name
Last Name
Reporter's Phone
*
(###)
###
####
Reporter's Email Address
*
Event Name (Tournament or League Game)
*
Date of Incident
*
MM
DD
YYYY
Time of Incident
*
Hour
Minute
Second
AM
PM
Location of Incident (Field #)
*
Choose one:
1
2
3
4
5
6
7
8
9
10
11
12
Incident Description
*
Provide full description of all events leading up to and including the incident.
Who responded to the incident:
*
Include all parties - Coaches, Tournament Director, Athletic Trainers, Security, Paramedics, etc. (Need Name and Phone Numbers)
Injured Person's Name
*
First Name
Last Name
Injured Person's Age
*
Injured Person's Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Injured Person's Phone
*
(###)
###
####
Injured Person's Gender
*
Choose One:
Female
Male
Injured Person's Postion:
*
Choose One:
Player
Coach
Umpire
Spectator
Is the Injured Person a USA Softball Member?
*
Choose One:
Yes
No
Please indicate which plan:
*
Choose One:
Individual Registration
Team Registration
Umpire Insurance
Tournament/Clinic Insurance
Unknown
Describe the Injury
*
How it occurred, where on body, right or left side, etc
Was First Aid Required?
*
Choose One:
Yes
No
Who provided First Aid Treatment?
First Name
Last Name
Description of Surroundings
*
Describe detailed description of surroundings, facility conditions, weather conditions, etc.
Other Comments
Signed of this date:
*
MM
DD
YYYY
