Incident Report Form printable pdf download

PECIAL

LYMPICS

/ I

IRST

EPORT OF

CCIDENT

NCIDENT

U.S. Program/Area: ____________________________ Date of Incident: _____________

Type of Injury/ Accident:

Injured Party:

Injured Person/Party Information

Date of Birth: ____/_____/_____

Age: ______

 Bodily Injury

 Athlete

 Volunteer

 Property Damage

Name: _____________________________________________________________________

 Coach

 Automobile

(Last)

(First)

(MI)

 Employee

 Other: _______________

Address: ___________________________________________________________________

 Spectator

(Street)

(City)

(State)

(Zip)

 Unified Partner

 Property Owner

Home Phone: (______)_______-________ Work Phone: (______)________-____________

 Other: _______

Gender:  Male

 Female

Social Security Number: ______-____-________

Description of Accident

(If automobile accident occurred, please attach a copy of the police report).

Describe how the accident occurred

_____________________________________________________________

(Attach a separate sheet if necessary):

__________________________________________________________________________________________________________________

__________________________________________________________

Sport

___________________________________________________________

 Alpine Skiing

 Power Lifting

 Aquatics

Site / event where accident occurred: _____________________________

 Relay Game

Body Part Injured:

 Head

 Athletics

 Roller Skating

 Neck

 Badminton

 Sailing

Disposition:

 Torso

Accident Occurred During:

 Baseball

 Snowboarding

 Released to parent

 Training/Practice

 Back

 Basketball

 Snowshoe

 Refusal of care

 Competition

 Hand

 Bocce

(L / R)

 Soccer

 Refer to doctor

 Traveling to or from SO event

 Finger

 Bowling

 Softball

(L / R)

 Refer to hospital or clinic

 Other: __________________

 Elbow

 Cheerleading

 Speed Skating

(L / R)

 Medical attention

 Shoulder

 Cross Country

 Swimming

(L / R)

 EMS transport

Type of Injury:

 Leg

 Table Tennis

(L / R)

 Severe cut w/ bleeding

Ski

 Patient requested EMS transport

 Knee

 Cycling

 Team Handball

(L / R)

 Less serious bruise or cut

 Released to personal vehicle

 Thigh

 Equestrian

 Tennis

(L / R)

 Break/fracture

 Police

 Shin

 Figure Skating

 Track & Field

(L / R)

 Concussion

 Ambulance

 Toe

 Floor Hockey

 Volleyball

(L / R)

 Paralysis

 Report only

 Other: _____________

 Golf

 Other: ________

 Fatality

 Other:

 Gymnastics

 Other:

Contact / Care Provider Information

If an athlete or underage volunteer was injured, please identify the care provider and/or responsible party (e.g. parent, legal

guardian).

Relationship to the injured person: _________________________

Employer Name: __________________________________________

Name: _______________________________________________

Employer Address: ________________________________________

Address: _____________________________________________

________________________________________________________

_____________________________________________________

Work Phone: (______)________-___________

Home Phone: (______)_______-________

 Yes  No

Does the injured person have medical insurance?

 Injured Person  Care Provider/Responsible Party

If yes, insurance is provided by:

Please provide name of Company and Policy Number: __________________________________________________

Witness Information

(Please provide names and phone numbers of any witnesses to the incident)

Witness #1 Name: _________________________________________________

Daytime Phone: (______)_______-________

Witness #2 Name: _________________________________________________

Daytime Phone: (______)_______-________

Special Olympics Official / Representative

(other than claimant)

Name: __________________________________________________________

Daytime Phone: (______)_______-________

Signature: _______________________________________________________

Send completed form to:

American Specialty Insurance Services, Inc., P.O. Box 459, Roanoke, IN 46783-0309; Fax: (260) 673-1291

If injury was serious or a fatality:

IMMEDIATELY notify American Specialty Insurance Services, Inc.

Telephone: (800) 566-7941 (24 hours a day / 7 days a week)

AMER: 189207 –SpecOlym Inc. Rep.Form 03-04

Incident Report Form

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