Injury Report Form

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 the injury occur: *

Name of person completing form: *

During what kind of activity did this injury occur? *

Sport Club Intramural Facility Rental Informal Recreation Well-being Center Other

If other, please specify:

If fingers or toes selected, please specify injured finger or toe:

Side of Injury:

Right Left Both

How did the injury occur? *

Action taken: *

Were University police called? *

Yes No

Was an ambulance called? *

Yes No

Was the member transported to the hospital? *

Yes No

Was the On-Duty Director called? *

Yes No

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