Injury Notification Direct Submission Form

This form must be completed for all injuries sustained during a BSA related activity that requires evaluation by a Physician or Health Practitioner ( ie 911 is called, player taken to hospital/clinic, concussion suspected, ect.)

A Team Official (Coach, Manager, ect.) who witnessed the incident must complete and submit this form within 24 hours.

Date of Injury

Please check this box and complete this form if the player sustained a concussive injury outside of a BSA related activity (ie at home, school, another activity). Concussion protocol will need to be followed before the player can return to play.

Player Name(s)

Age Group

Team Name

Location of Injury (Field Name, City, ect.)

Injuries Sustained ( List symptoms )

Describe Incident

Emergency Medical Services called ?

Yes

Hospital/Medical Clinic where player was transported to

Mode of transportation to Hospital/Clinic

Parent(s)/Guardian(s)/Caregiver(s) of Player

Was person(s) listed above advised ?