Injury/Concussion Reporting (Clarington Baseball Association)

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Injury/Concussion Reporting

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Injury/Concussion Reporting

Is This An Initial Report (First Report), Or A Follow Up Report (E.g. Update)^*

Initial / first reportFollow up report / update

Required

What Program Is The Injured Person Involved In?^*

Blastball
Jr. House League (T-Ball, Blastball)
House League (Rookie to Midget)
Select
Elite
Umpire

Check All That Apply

What team is the injured person with?^*

Required

Injured Person's Name^*

Required

First & Last

The following fields will collect details of the injury or event. If the injury/event occurred in another sport or activity, please provide as much information as known.

Who Is Reporting This Injury / Event Or Update?^*

Athlete (or parent/guardian on behalf of athlete)
Coach/Trainer
Umpire (or parent/guardian on behalf of umpire)
Other

Check All That Apply

Has the team's head coach been notified?^*

Yes
No
Don't Know

Required

Has the the individual's parent/guardian been notified of the injury and Removal from sport (if applicable)?^*

Yes (please add name and date of notification)
No
Not Applicable (adult injury)

Required

If answered yes to above, please add name and date of notification

Medical Assessments & Status In Sport (Upload Medical Assessments Received)

Medical assessment confirms NO concussion, NO restrictions on participation in sport
Medical assessment confirms CONCUSSION, remains REMOVED from sport
Medical assessment permits RETURN to sport, with restrictions
Medical clearance received, FULL RETURN to sport
Other, please specify below

If you answered Other to above, please specify

File Upload

Allowed extensions: .jpeg, .jpg, .png, .gif, .pdf, .doc, .docx, .xls, .xlsx, .ppt, .pptx.
Maximum # Files: 1. Maximum File Size: 4MB.

Additional Information (If Required)

Name Of Person Submitting This Report^*

Required

First and Last Name

Email Address Of Person Submitting This Report^*

Required

First and Last Name

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