Injury/Concussion Report Is this an initial report (first report), or a follow up report (e.g. update) * Initial / first report Follow up report / update What program is the injured person involved in? * Blastball Jr. House League (T-ball, 4-Pitch) House League (Rookie to Midget) Select Rep Umpire Injured person's role: * Athlete/player Coach/Trainer Other (please specify)Other (please specify) What team is the injured person with? * First Name of injured person * First Last Name of injured person * LastThe 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. Injury/Event Date Injury/Event Time (approximate) Where did the injury/event take place? (e.g. diamond name, gym, etc.) Describe the injury / event (brief description) * 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 (please specify)Other (please specify)Has the team's head coach been notified? * Yes No Concussion Protocols (check all that apply) Injury is a suspected/confirmed concussion, individual Removed from Sport Injury required first aid Injury required emergency aid (e.g. 911, hospital) Other (please specify)Other (please specify)Has the the individual's parent/guardian been notified of the injury and Removal from sport (if applicable)? * No Yes (please add name and date of notification)Yes (please add name and date of notification) Not Applicable (adult injury) 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)Other (please specify)File Upload Drop a file here or click to upload Choose File Maximum upload size: 134.22MB Additional Information (if required) reCAPTCHA Name of person submitting this report Email address of person submitting this report If you are human, leave this field blank. Submit
