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Injury Report Form

Reports should be filled out immediately after an injury occurs.

*Indicates a required field. If you are unable to obtain information, enter N/A.

* Name of member/victim:

* Member's phone number:

* Member's email address:

* Type of Member:
Student
Faculty/staff
Alumni
Community
Guest

* Date of birth:

* University ID#:

* Date of injury:

* Time of injury:

* Where did injury occur:

* Name of person completing form:

* During what kind of activity did this injury occur?
Sport Club
Intramural
Facility Rental
Informal Recreation
Other:

* Location of injury (select all that apply):
Head
Facial
Oral
Neck
Back
Ankle
Abdomen
Chest/Rib
Hip
Groin
Elbow
Knee
Wrist
Foot
Shoulder
Upper Arm
Thigh
Forearm
Lower Leg
Hand
Fingers or Toes (please specify injured finger or toe)

Side of injury:
Right
Left
Both

* How did injury occur:

* Action taken:

* Were University police called? Yes No

* Was an ambulance called? Yes No

* Was the On-Duty Director called? Yes No

If University Police or an ambulance were called, please remember to call the On-Duty Director at (804) 335-6791.

Name of witness:

Witness' phone number:

Witness' email address: