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Home Campus Recreation

Campus Recreation Accident/Injury Report

Campus Recreation

Programs
Facilities & Hours
Member Services
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Contact

Participant Name

D.O.B

ID (if applicable)

Phone

Address

Accident/Injury Information

Time/hour

Time/minutes

A.M./P.M.

Date

Status

UML Student

Non-UML Student, please list the name of the university

Faculty/Staff

CRC Member

Spectator

Other

Location

Outdoor Center & Bike Shop

Campus Recreation Center (please list activity area)

Campus Rec Turf Complex

Mini Turf in Front of Rec Center

Cushing Field

Kayak Center/Boathouse

Mahoney Gym

Riverview Fitness Center

Riverview Studios

Tsongas Center

South Campus Field/Courts

Off Campus (please list)

Other

Activity Type

Club Sports (please list which Club)

Free Wheelers

Group Fitness

Intramural Sports

Instructional/Learn To

Kayak/Canoe

Open Recreation

Outdoor Adventure Program

Personal Training

Rental (Please list)

Other

Type of Injury/Accident

Allergic Reaction

Concussion

Dislocation

Dizzy/Faint

Fracture

Frostbite

Heart Attack

Hypothermia

Laceration (Small Cut/Scratch)

Laceration (Large Cut/Open Wound)

Seizure

Sprain/Strain/Bruise

Stroke

Other

Part of Body

Ankle

Arm

Back

Chest

Ear

Elbow

Eye

Finger

Foot

Forearm

General

Hand

Head

Hip

Jaw

Knee

Leg

Lungs

Mouth

Neck

Nose

Pelvis

Shoulder

Spine

Stomach

Thigh

Wrist

Other

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

Please list name of Campus Recreation Student Supervisor or AT filling out this Report

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Campus Recreation
UMass Lowell
322 Aiken Street, Lowell, MA 01854
Phone: 978-934-5080 | Email: justin_lawler@uml.edu

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