Injury Report (CYO Minor Hockey)
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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
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Where did this happen?
Date and Time injury occured
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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
*
Select One...
Mite
Tyke
Novice
Atom
Peewee
Bantam
Midget
Juvenile
Alumni
Heat
First Shift
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?
*
Yes
No
If YES, Hockey Canada concussion protocols must be followed.
Head
Throat
Eye Area
Dental
Face
Skull
Check All That Apply
Back
Neck
Upper
Lower
Check All That Apply
Trunk
Ribs
Chest
Abdomen
Check All That Apply
Pelvis
Left Hip
Right Hip
Groin
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 Ankle
Left Toe
Right Ankle
Right 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?
*
No
Yes, by car
Yes, by ambulance
Brief Description of Injury
To receive a copy of this submission please enter your email address here
*
Example:
[email protected]
Your submission will be sent to this address.
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Printed from cyominorhockey.com on Sunday, January 24, 2021 at 9:52 AM
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