Accident Report Form
Date of Incident
_____/_____/_____
Winthrop University Police Notified __________________
Time of Incident ___________ am / pm
Officer Name/Badge # ___________
Case # _________
EMS Notified _________ Time of Arrival ____________
PERSONAL DATA
Gender:
Name _________________________________________________________
ID # (WUID/DL#/SS#) ___________________
Local Address __________________________________________________
Date of Birth:
Cell Phone ________________
Status: ___ Student
___ Faculty/Staff
___Guest
Male
___Other: __________
Female
_____/_____/_____
School: __________________________
If under 18, name and phone number of parent/legal guardian: ________________________________________________________________________________
DETAILS OF ACCIDENT
Building/Area of Accident: ____Gymnasium
____Rec Fields
____Pool
____Weight Room
____Softball Complex ____Activity Room 122
____Racquetball Court
____Activity Room 206
____Climbing Wall
____Track
____Other: _______________________________________
Location within building/area (court #, field #, machine description, etc.) _______________________________________________________________________
Program participating in: (check all that apply)
___ Open Recreation
___ IM (sport) _____________
___ Aquatics
___ Fitness Class
___ Personal Training
___ Camp
___ Club Sports ____________
___ Academic Class
___Other: ____________________
DETAILS OF INJURY
Part of Body Injured: (check all that apply)
___ Left
___ Right
___ N/A
___ Head
___ Face
___ Ear
___ Mouth
___ Teeth
___ Eye
___ Nose
___ Neck
___ Shoulder
___ Arm
___ Wrist
___ Hand
___ Finger
___ Torso
___ Back
___ Ribs
___ Hip
___ Groin
___ Leg
___ Knee
___ Ankle
___ Foot
___ Toe
___ Other: ___________________________________________________________________________
Suspected Classification of Injury:
___ Laceration/Cut
___ Strain
___Break
___ Sprain
___ Fracture
___Dislocation
___ Contusion/Bruise
___ Concussion
___Airway
___ Cardiac
___ Sudden Illness
___ Other: _____________
Description of how injury occurred: (specify events leading to the accident/injury)
___ Collision with obstacle
___ Collision with person
___ Hit by projectile
___ Pre-existing
___ Equipment Related
___ Non-Contact
___ Sudden turn or stop
___ Unknown
___ Fall
___ Swim Rescue
___ Other: ____________________________
Describe in greater detail: (attach additional information if necessary/more room on back)
__________________________________________________________________________________________________________________________________
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IMMEDIATE ACTION TAKEN
First Aid rendered: (check all that apply)
___ Applied Ice
___ Stopped Bleeding
___ CPR
___ Rescue Breathing
___ AED
For Aquatics Use Only:
Name of care giver: _______________________
___ Immobilized
___Elevated
___ Washed Wound
Position: ________________
___ Victim Self Care
___ Bandage
___ None
___ Other: ______________________________
___ Assisted Rescue
___ Oxygen
___ Passive Rescue
___ Backboard
Describe in greater detail: (attach additional information if necessary/more room on back)
__________________________________________________________________________________________________________________________________
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Further Care: (check all that apply)
___ Ambulance to hospital (what hospital) __________________
___ Went home on own
___ Returned to activity
___ Friend took home
___ Self/Friend to hospital (what hospital) __________________
___ Left area no info
___ Self/Friend to Health Center
___ Referred for treatment
If transported by friend, name of friend: ____________________________________________ Cell Phone: _____________________________________
FACILITY DATA
Number of Patrons in the area at time of the incident: ____________________________________
Facility employees on duty at time of the incident:__________________________________________________________________________________________
Additional staff supervising at time of the incident:(i.e. Intramural staff, Fitness staff, etc.) _________________________________________________________
Describe condition of the area at the time of the incident:
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Witness: _______________________
Phone: ______________________
Address: ___________________________________________________
Witness: _______________________
Phone: ______________________
Address: ___________________________________________________
ADDITIONAL NOTES:
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I, the injured party, herein certify that the information set forth above is true and correct to the best of my knowledge. At this time, I am refusing further care from
Winthrop University Recreational Services Department.
Injured Signature: _________________________________________________________________________________________
Date ____/____/____
Signature of Parent/Legal Guardian (if victim is a minor) __________________________________________________________
Date ____/____/____
Name of Staff member filling out report (print clearly) _________________________
Date ____/____/____
Signature ________________________
FOLLOW-UP REPORT
Reviewed by: _____________________
Position: ___________________________
Date ____/____/____
Call Log:
Attempt # 1:
Date ___/___/___
___ Left Message
Attempt # 2:
Date ___/___/___
___ Left Message
Attempt # 3:
Date ___/___/___
___ Left Message
Time __________
___ Left Message with Person
Time __________
___ Left Message with Person
Time __________
___ Left Message with Person
Caller Signature: _____________________________________________________
___ Spoke with injured person
___ No answer
Caller Signature: _____________________________________________________
___ Spoke with injured person
___ No answer
Caller Signature: _____________________________________________________
___ Spoke with injured person
___ No answer
STATUS OF INJURED PERSON
Date ____/____/____
Time __________
Caller Signature: _____________________________________________________
___ The injured person is fine. No complications.
___ Unknown. Unable to contact the injured person after 3 attempts.
___ The injury was serious enough to warrant additional medical attention. The injury was diagnosed as______________________________________________
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