Above The Dirt Sports
Injury / Incident Report
Event Information
Date: __________________________________________________
Location / Field: __________________________________________________
Tournament or game: __________________________________________________
Team(s) involved: __________________________________________________
Weather / field conditions: __________________________________________________
Injured Party
Full name: __________________________________________________
Date of birth: __________________________________________________
Phone: __________________________________________________
Emergency contact & phone: __________________________________________________
Role (player / umpire / spectator / staff): __________________________________________________
Incident Details
Time of incident: __________________________________________________
Body part(s) affected: __________________________________________________
Description of what happened:
Immediate action taken (first aid, ice, 911, etc.):
Was medical transport called? ☐ Yes ☐ No
Was the participant able to continue? ☐ Yes ☐ No
Witnesses
Name & phone: __________________________________________________
Name & phone: __________________________________________________
Reported by (printed): _____________________________________
Role: _______________________________ Phone: ______________
Signature: __________________________________ Date: ______________
Submit completed form to a board member within 24 hours.