Injury Report Form

Sport Club: _______________________

1. Athlete’s Name: _________________________ SS#: ___________________

2. Local Address: _________________________ Tel. #: _________________

3. Year in School: _____________________

4. Injured Body part: _____________________ ______Right ____Left

5. Date of the Injury: __/___/___ Time: _______ Location: __________

6. Did the injury occur during a game or practice? _______________

7. Description of injury (what happened & how did it happen, conditions (weather, field) etc.):

8. Initial Treatment/Action taken (what was done, by whom, and if transported, to where):

9. Witnesses:

a. _______________________

b. _______________________

c. _______________________

Submitted by (Please print): ____________________ Date: ________________

Signature: ______________________

In the event and injury occurs, the following offices should be called:

WCU Public Safety 227-7301

Health Services 227-7640

Emergency 911

Debby Schwartz (W) 227-3553

(H) 277-8143 (C) 712-7450

Please return by the next business day to the Intramural Office, Reid Fitness Center