UNIVERSITY OF WISCONSIN – EAU CLAIRE ACCIDENT/INJURY REPORT
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UNIVERSITY OF WISCONSIN – EAU CLAIRE ACCIDENT/INJURY REPORT All accidents are to be reported immediately. Forward this accident report to the Sport Clubs Coordinator. Name of Injured:____________________________________________ Sex:__________ ID Number:________________________________________________ Local Address:_____________________________________________ Local Phone:_______________________________________________ Status (circle one) Student Staff Faculty Guest Other:________ Date of Injury:______________________________________________ Time of Injury:_____________________________________________ ///////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// Nature of suspected/stated injury or illness: (check below) _____Abrasion _____Burn/Scald _____Dislocation _____Fracture _____Inhalation _____Puncture _____Amputation _____Bleeding _____Bruise _____Concussion _____Convulsion _____Cramps _____Drowning _____Fainting _____Foreign Body _____Heart _____Heat Exhaustion _____Heat Stroke _____Internal Injury _____Laceration _____Poisoning _____Shock (specify) _____Sprain/Strain _____Suffocation Other:_______________________________________________________________________________________________ ////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// Part of the body that was injured: (Mark R for right and L for Left) _____Generalized _____Mouth _____Spine _____Pelvis _____Wrist _____Knee _____Skull/Scalp _____Eye _____Eye _____Tongue _____Tooth _____Jaw _____Chest _____Lungs _____Abdomen _____Shoulder _____Upper Arm _____Elbow _____Hand _____Finger(s) _____Hip _____Lower Leg _____Ankle _____Foot _____Nose _____Neck _____Back _____Forearm _____Thigh _____Toe Other:_______________________________________________________________________________________________ ////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// Facility at which accident occurred: (check below) _____Ade Olson _____Putnam Volleyball Courts _____Bollinger Fields _____McPhee _____Bridgman Basketball Courts _____Rec Fields 4 & 5 _____Zorn Arena _____Oakridge Volleyball Courts _____Broomball Rink _____Towers Fields _____Governors Volleyball Courts _____Soccer Fields _____Tennis Courts _____Bowling & Billiards Center _____Crest Wellness Center Other:_______________________________________________________________________________________________ ////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// Please specify the exact location (i.e. Room # or Field/Court Number) of the accident and the conditions in which the accident occurred._______________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ (Over) C-6 HOW DID THE INJURY OCCUR? (Describe fully the events, actions, and conditions which contributed to the injury.) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ PRECISE EXPLANATION OF ACTION TAKEN:_____________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Care of Injured transferred to: Name:____________________________________________________________________________________ Position:__________________________________________________________________________________ Police called? Yes No Time Called:_______ Arrival Time:_______ Ambulance called? Yes No Time Called:_______ Arrival Time:_______ Sent to Health Services? Yes No Sent to Hospital/Clinic? Yes No Specify:____________________________ Refusal of Treatment? Yes No Signature:__________________________ Refusal of Transport? Yes No Signature:__________________________ ///////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// WITNESSES: Name___________________________Address_____________________Phone__________ Name___________________________Address_____________________Phone__________ Name___________________________Address_____________________Phone__________ ///////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// FOLLOW-UP AND SPECIAL REMARKS:____________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ///////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// Prepared By (please print):_______________________________________________ Position:_______________________________________ Date:___________________ ///////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// **OFFICE USE ONLY** Reviewed By:______________________________________________________________ Position:_______________________________________ Date:___________________