Player Name *

Suspected Concussion Yes No *

Date of Injury ...

Team 2-3 Chinooks 2-3 Cougars 2-3 Cubs 2-3 Ducks 2-3 Lightning 2-3 Sharks 2-3 Vandals 4-5 Bears 4-5 Beavers 4-5 Bruins 4-5 Cardinals 4-5 Coyotes 4-5 Falcons 4-5 Hawks 4-5 Mustangs 4-5 Packers 4-5 Panthers 4-5 Rebels 4-5 Lightning 4-5 Sharks 4-5 Thunder 4-5 Tigers 6 Beavers 6 Cardinals 6 Chieftains 6 Falcons 6 Grizzlies 6 Hawks 6 Huskies 6 Panthers 6 Raiders 6 Seahawks 6 Sharks 6 Tigers 6 Titans 7 Aztecs 7 Coyotes 7 Falcons 7 Hawks 7 Kunz 7 Panthers 7 Sharks 7 Texans 7 Thunder 7 Tigers 7 Titans 8 Beavers 8 Falcons 8 Hawks 8 Rose 8 Thunder 8 Tigers Black 8 Titans Orange 8 Vandals 8 Wolves *

Field Location *

Players Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Team Offense Defense *

Position Played at time of Injury Center (C) Guard (G) Tackle (T) Tight End (TE) Running Back (RB) Quarterback (QB) Wide Receiver (WR) Def. Line (DL) Linebacker (LB) Def. Back (DB) *

Time of Injury (If during Practice)

Time of Injury (If druing game) 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Over Time

Field Conditions Dry Wet Mud Snow Ice *

Type of Field Grass Field Turf *

How Injury Occured - IF CONTACT Injury (Check all that apply) Tackling
Getting tackled
Blocking
Getting Blocked
Incidental:
Contact with the ground
Contact with helmet
Contact with cleats
Contact with on/off-the-field obstruction: Coach
Contact with on/off-the-field obstruction: Player
Contact with on/off-the-field obstruction: Official
Contact with on/off-the-field obstruction: Yardsticks
Contact with on/off-the-field obstruction: Goalpost
Contact with on/off-the-field obstruction: Bench
Contact with on/off-the-field obstruction: Fence
Contact with on/off-the-field obstruction: Spectator

How Injury Occured - If NONCONTACT Injury (Check all that apply) Cutting Pivoting or Twisting Jumping

Weather (Check appropriate) Rain Hot Cold Windy *

Weather Temperature *

Type of Play Run Pass Kickoff Kickoff Return Punt Punt Return Other *

Body part affected: (checkall that apply) Head/Neck
Suspected Concussion
Upper Arm (Right)
Upper Arm (Left)
Lower Arm/Wrist (Right)
Lower Arm/Wrist (Left)
Back/Spine
Pelvis/Groin/Hip (Right)
Pelvis/Groin/Hip (Left)
Knee (Right)
Knee (Left)
Foot/Ankle (Right)
Foot/Ankle (Left)
Shoulder (Right)
Shoulder (Left)
Elbow (Right)
Elbow (Left)
Chest/Ribs/Abdomen
Upper Leg (Right)
Upper Leg (Left)
Lower Leg (Right)
Lower Leg (Left)
*

New Injury? Yes No *

Previous injury when? (if applicable)

Return to Play? Yes No *

Symptoms/Concerns Prior to Practice/Game? Yes No *

If concerns, did you hold athlete out? Yes No

Describe Injury and care given: *

Player’s Description of Injury (Subjective):

Coaches Name *

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