University of Wisconsin Eau Claire

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 _____Amputation _____Bleeding _____Bruise _____Burn/Scald _____Concussion _____Convulsion _____Cramps _____Dislocation _____Drowning _____Fainting _____Foreign Body _____Fracture _____Heart _____Heat Exhaustion _____Heat Stroke _____Inhalation _____Internal Injury _____Laceration _____Poisoning _____Puncture _____Shock (specify) _____Sprain/Strain _____Suffocation

Other:______////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// Part of the body that was injured: (Mark R for right and L for Left) _____Generalized _____Skull/Scalp _____Eye _____Eye _____Nose _____Mouth _____Tongue _____Tooth _____Jaw _____Neck _____Spine _____Chest _____Lungs _____Abdomen _____Back _____Pelvis _____Shoulder _____Upper Arm _____Elbow _____Forearm _____Wrist _____Hand _____Finger(s) _____Hip _____Thigh _____Knee _____Lower Leg_____Ankle _____Foot _____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:______