Campus Recreation Accident/Injury Report

Participant Name

D.O.B

ID (if applicable)

Phone

Address

Accident/Injury Information

Time/hour

Time/minutes

A.M./P.M.

Date

Witnesses [For major injuries ONLY]

Witness #1

ID (if applicable)

Phone

Witness #2

ID (if applicable)

Phone

Describe Accident

Describe care given

Called EMS?

Yes

No

Refuse EMS attention?

Yes

No

Transported to hospital?

If Yes, name of hospital

No

Person filling out report

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