ACCIDENT REPORT
REPORT DATA
Date:
Time of Injury:
PERSONAL DATA
Name of Injured:
am / pm
 Female Male
AU/JFC ID Number:
Address or Mailstop:
Phone:____________________________________________
Age:
Date of Birth:
/
/
.
Email:__________________________________________________
AU Affiliation:
LOCATION OF ACCIDENT
Front Desk/Lobby
Bender Arena
 Wrestling room
Reeves Aquatic Center Pool
Locker rooms (M/W)
Cardio 2nd level
IM Fields specify which field________________  Strength area 1st level
Group X Room
Other___________________________________
PROGRAM Area– Include Specific Activity in Space Provided
 Aquatics ____________________
 Club Sports ________________  Fitness _____________________
 Informal ____________________
IM________________________  Other ______________________
NOTIFICATIONS
Manager on Duty Notified:
YES
NO
Name: ________________________________________
Were Campus Police called?
YES
NO
Responding officer_____________________________
Report number________________________________
Spill kit used?
YES  NO
Was area/equipment contaminated?
YES  NO

If yes, specify area/equipment:
_______________________________________________
Was area/equipment disinfected? YES  NO
INJURY DATA
 Head
 Face
 Neck
 Abdomen
 Torso
 Back
 Other
_______________
R







L







Part of Body Injured
R L
Eye
  Hand
Ear
  Finger
Shoulder
  Ribs
Upper Arm   Pelvis
Elbow
  Groin
Forearm
  Hamstring
Wrist
R






L






Quad
Knee
Shin
Ankle
Foot
Toe
FIRST AID DATA – Check all that apply
General
 Applied Ice
 Stopped Bleeding
 Immobilized
 Elevated
 Washed Wound
 Bandaged
CPR/AED
 Rescue Breathing
 CPR
 AED
Other
 Victim Self-Care
 None
Aquatics
 Deck Assisted Rescue
 Distressed Swimmer
 Active Drowning Victim
 Passive Drowning Victim
 Suspected Head, Neck, Spine
 Spine Board
Further Care
 Ambulance to Hospital
Location:_____________________
Time:________________________
 Campus Police Transport
Location:_____________________
Time:________________________
 Rec. Sports Admin. Notified
Who:________________________
Time:________________________
 Home on Own
 Returned to Activity
 Taken by Friend Home/Dorm
 Athletic Trainer Transport
Responder Information:
Who Provided Care (name/position):
____________________________
____________________________
____________________________
____________________________
____________________________
First Aid Supplies Used:
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
Detailed Description of Accident:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
___________________________________________________________________________ (use additional paper if needed or type description)
Complete Both Sides
Refusal of Care: I, the injured party, have been advised that I may have a medical condition(s) which may require an examination
by medical personnel. At this time, I am refusing the care given by the personnel listed on this form and require no further treatment
from the American University Recreational Sports and Fitness department.
Signature of Injured:
Time:
Witness of Refusal:
Phone:
Recreational Sports Personnel:
Title: ____________________
Refusal of Transport: I understand that at my discretion, I can refuse official transport to a licensed health care facility. I
understand that by signing this refusal I release American University and its agents from all responsibility for any claim rising from
this decision.
Signature of Injured:
Time:
Witness of Refusal:
Phone:
Recreational Sports Personnel:
Title: ____________________
WITNESS 1
Address or Mailstop:
Printed Name
Phone
Signature
Email
Account of What Happened
I, the injured party, herein certify that the information set forth above is true and correct to the best of my knowledge.
Signature of Injured:
Time:
Recreational Sports Personnel:
Title:
Report Prepared by (Print Full Name(s) clearly): ____________________________________________ Position: ___________________________
Signature: ____________________________________________________ Name of Administrator(s) Notified: ____________________________
OFFICE DATA
Status:  Submitted
Date of Follow-Up:
 Forwarded to Administrator for Follow-Up
Follow-Up Comments:
*Rec Sports supervisor had right to refuse continued participation
Administrator:
