La Pine Sports Academy
Injury & Incident Reporting Form
This form must be completed for any injury or illness occurring during an LPSA activity, practice, game, camp, or event.
1. Participant Information
Full Name: ____________________________________________
Address: _______________________________________________
Date of Birth: ____ / ____ / ______
Gender: ☐ Male ☐ Female
Team: __________________________
Coach: _________________________
Location of Incident: _________________________________
Date of Incident: ____ / ____ / ______
Time: __________ ☐ AM ☐ PM
Injured Person (circle one):
Player / Referee / Coach / Spectator
2. Type of Activity at Time of Injury
☐ Training
☐ Warm-up
☐ Competition
☐ Cool-down
☐ Other: __________________________
3. Reason for Evaluation
☐ New injury
☐ Aggravated injury
☐ Recurrent injury
☐ Illness
☐ Other: __________________________
4. Body Part(s) Injured
Describe and circle body area if applicable:
5. Nature of Injury / Illness
☐ Bruise / Contusion
☐ Concussion (suspected or confirmed)
☐ Sprain (ligament injury)
☐ Strain (muscle injury)
☐ Fracture (suspected or confirmed)
☐ Dislocation / Subluxation
☐ Inflammation / Swelling
☐ Loss of consciousness
☐ Respiratory issue
☐ Skin injury (cut, scrape, blister)
☐ Cardiac concern
☐ Illness (cold/flu/other)
☐ Overuse injury
☐ Unspecified medical condition
☐ Other: __________________________
6. Cause of Injury
☐ Collision with fixed object
☐ Collision with another player
☐ Fall / awkward landing
☐ Slip / trip / stumble
☐ Struck by ball or object
☐ Struck by another player
☐ Overexertion
☐ Overuse
☐ Temperature-related (heat, smoke, cold)
☐ Other: __________________________
7. Incident Description
Explain how the incident occurred:
Were there contributing factors? (equipment, surface, footwear, foul play, etc.)
Was protective equipment worn? ☐ Yes ☐ No
If yes, what? ___________________________________________
8. Action Taken
☐ None required
☐ RICER (Rest, Ice, Compression, Elevation, Referral)
☐ Dressing / Bandage
☐ Sling / Splint
☐ Immobilization
☐ Strapping / Taping
☐ Stretching / Exercises
☐ CPR
☐ Transported from field/court
☐ Medical evaluation recommended
☐ Ambulance called
☐ Other: __________________________
9. Return to Play Status
☐ Immediate return to activity
☐ Return with restrictions
☐ Unable to return at this time
☐ Referred for further medical assessment
10. Referral
☐ No referral
☐ Medical practitioner
☐ Physiotherapist
☐ Hospital
☐ Ambulance
☐ Other: __________________________
11. Provisional Severity Assessment
☐ Mild (1–7 days modified activity)
☐ Moderate (8–21 days modified activity)
☐ Severe (21+ days modified or lost participation)
12. Parent / Guardian Notification
Parent/Guardian notified: ☐ Yes ☐ No
Time notified: ______________________
The injured person and/or guardian was advised that if symptoms do not improve within 24 hours, they must seek further medical evaluation.
☐ Yes ☐ No
13. Treating Person
☐ Sports Trainer / First Aider (ID: ________)
☐ Medical Practitioner
☐ Physiotherapist
☐ Other: __________________________
Name of Treating Person: _______________________________
Signature of Treating Person: ___________________________
Date: ____ / ____ / ______
Signature of Parent / Guardian: _________________________
Date: ____ / ____ / ______