Incident Report

This form should be filled out if any type of first aid has been performed (anything more than give a bandaid)

What location are you filling this out for?(Required)

Bonnyville

Fort McMurray

Red Deer

Did the the athlete sustain a head injury?(Required)

Yes - View the attached PDF for more information on how to manage head injuries

No

Patient Information

Please enter information for the person receiving First Aid Treatment

Patients Name(Required)

First Last

Birthdate(Required)

Known Medical Conditions/Allergies/Medication(Required)

Patient (or Guardian) Phone Number(Required)

Parent (or Guardian) Email(Required)

Incident Information

Please enter all information regarding the incident

Date of Incident(Required)

Time of Incident(Required)

:

Time of First Intervention(Required)

:

Time of Medical Support Arrival (if applicable)

:

Did a head injury occur(Required)

Yes

No

Charge Person - Describe the Incident (What took place, Where it took place, What were the signs and symptoms of the Patient)(Required)

Event and Conditions (what was the event during which the incident took place - example: practice, showcase etc., location of incident - where in the gym? etc, surface quality - example lighting, spills, etc.)(Required)

Actions taken/intervention(Required)

After treatment, the patient was:(Required)

Sent home

Sent to hospital

Returned to sport

Other

Charge Person Information

Name of the person providing first aid(Required)

First Last

Phone Number(Required)

ROLE (Coach, assistant, parent, official, bystander, therapist):(Required)

Witness Information

Someone who observed the incident and response, not the charge person

Name(Required)

First Last

Form Completed By

Please enter the information for whomever is filling out this form

Name(Required)

First Last