Injury Report (CYO Minor Hockey)

Print Injury Report

Please fill out all information. This form will be sent automatically to the Director of Risk, the President and the Secretary. It is imperative that any injury be documented in a timely fashion. Only when an injury is documented can we properly investigate and appropriately follow up.

I will also fill in the ALLIANCE INJURY REPORT FORM. This form is to be filled in by a physician and mailed to the address located at the bottom of the form.

I understand that I must fill in the OHF injury report form and send to Alliance^*

Where did this happen?

Date and Time injury occured^*

Open the calendar popup.

Open the time view popup.

Arena/Place the injury occured^*

Who was injured

Name of person injured^*

please enter first and last name of injured person
Parish/Program^*

enter the parish or program this person is affiliated with
Team name^*
Division^*

Trainers Information

Trainer's name^*
Trainer's phone number^*
Trainer's email^*

Example: [email protected]

Identify the nature of the injury

Is the injury a possible concussion?^*
YesNo
If YES, Hockey Canada concussion protocols must be followed.
Head
ThroatEye AreaDentalFaceSkull
Check All That Apply
Back
NeckUpperLower
Check All That Apply
Trunk
RibsChestAbdomen
Check All That Apply
Pelvis
Left HipRight HipGroin
Check All That Apply
Arm
Left Shoulder
Left Elbow
Left Upperarm
Left Hand/Finger
Left Forearm/Wrist
Left Collarbone
Right Shoulder
Right Elbow
Right Upeerarm
Right Hand/Finger
Right Forearm/Wrist
Right Collarbone
Check All That Apply
Foot
Left AnkleLeft ToeRight AnkleRight Toe
Check All That Apply
Leg
Left Thigh
Left Knee
Left Shin
Right Thigh
Right Knee
Right Shin
Check All That Apply
Other

What happened

Was the injured person sent to Hospital or Urgent Care?^*
NoYes, by carYes, by ambulance
Brief Description of Injury

To receive a copy of this submission please enter your email address here^*

Example: yo[email protected]. Your submission will be sent to this address.

Human Validation

Check The Box ^*