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Incident/Injury Tracking Report
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2023-01-13T05:54:35-05:00
Incident/Injury Tracking Report
Please enable JavaScript in your browser to complete this form.
Injured Person's Name
*
Date of Birth:
*
Age:
*
Gender
*
(Choose)
Male
Female
Address:
*
Parent's Name:
*
Home Phone:
*
Alternate Phone:
Incident Date:
*
Incident Time:
*
Field Incident Occurred On:
*
(Choose)
Rossie 1
Rossie 2
Williams Beach
Sutton Park
Farquhar Field
Cutler Middle School
Old Mystic Baptist Church
Butler Elementary School
Pawcatuck
Washington Park
Incident Occurred While Participating In:
*
(Choose)
Tee Ball
AA Baseball
AAA Baseball
AAA Softball
Majors Baseball
Majors Softball (9/10)
Majors Softball (11/12)
Juniors Softball
Seniors Softball
Babe Ruth (13-15)
Babe Ruth (16-18)
Incident Occurred During:
*
(Choose)
Practice
Game
Tryout
Tournament
Travel To
Travel From
Special Event
Other
Position/Role of Person Involved in Incident:
*
(Choose)
Batter
Base Runner
Pitcher
Catcher
First Base
Second Base
Third Base
Shortstop
Outfield
Dugout
Umpire
Manager/Coach
Spectator
Other
Type of Injury:
*
Was First Aid Required:
*
(Choose)
Yes
No
If first aid was required, what:
*
Was Professional Medical Treatment Required:
*
(Choose)
Yes
No
If professional medical treatment was required, what:
*
Incident Type and Location:
*
(Choose)
Base Path: Running
Base Path: Sliding
Hit by Ball: Pitched
Hit by Ball: Thrown
Hit by Ball: Batted
Collision with: Player
Collision with: Structure
Grounds Defect
Seating Area
Parking Area
Concessions Area
Travel: Car
Travel: Bike
Travel: Walk
Other
Please give a short description of incident:
*
Could this incident been avoided? How:
*
Prepared By/Position:
*
Phone Number
*
Date:
*
Send Confirmation Email to:
*
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