Accident Report

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This Accident Report is used to document any accidents or injuries that may occur in the facility throughout the day.

Today's Date: Time of Injury: Time Notified:
Name: Age: Gender (circle):  M   F
Phone: Email:
Are you affiliated with the University of Pennsylvania?  YES   NO
If YES, what is your affiliation?
Nature of Injury:
  Contusion Dislocation Fracture Sprain Other
Type of Activity:
  Free-Play Club Sports Group Rental Intramural Sports  
Part of Body Injured:
Abdomen Ankle Back Elbow Foot Forearm
Face Finger Groin Hamstring Hand Head
Knee Neck Pelvis Quads Ribs Shin
Shoulder Thorax Toe Upper Arm Wrist Other
Location of Accident:
Description of Accident:
Witness Name (1): Phone #:
Witness Name (2): Phone #:
Action Taken:
First Aid by: Transported to:
Method of Transport:
  Ambulance Private Auto Police Other