|
Is this report for BOYS or GIRLS (please select):
|
|
|
|
School Name (please select):
|
|
|
|
School Classification (please select):
|
|
|
|
Who provides medical coverage during majority of VARSITY contests (please select):
|
|
|
|
Who provides medical coverage during majority of NON-VARSITY contests (please select):
|
|
|
|
ONLY INDICATE INJURIES SERIOUS ENOUGH TO REQUIRE A PLAYER (grades 9-12) TO MISS ONE OR MORE GAMES. COMPLETE THIS FORM EACH TIME AN INJURY OCCURS - ONE FORM PER INJURY.
|
|
Please select action at the time of injury:
|
|
|
|
Was this a season ending injury (please select):
|
|
|
|
When Did the Injury Occur (please select):
|
|
|
|
Body Part Injured (select one):
|
|
|
|
If you said "other" in the above question, please explain:
|
|
|
|
Examined by Medical Professional:
|
|
|
|
Was Surgery Required (please select):
|
|
|
|
Hospitalization Required:
|
|
|
|
If you said "yes" to hospitalization, what was length of stay:
|
|
|
|
Was the injury the result of contact (please select):
|
|
|
|
If result of contact, please specify:
|
|
|
|
If this injury occurred at a base, what base?
|
|
|
|
Is this an overuse throwing/pitching injury?
|
|
|
|
How many games were missed (please select):
|
|
|
|
Thank you for your information, please hit submit below to submit your responses.
|
|