Physical Education Accident Report Form - Idaho State University

The accident occurred during: (place an “X” in the appropriate space)
_____ Recreational/Club activity         _____ Physical Education Activity Class         _____ Intramural Activity

Specific Physical Activity:__________________________ Supervisor/Instructor________________________

Date & Time of Accident:___/___/___, ___ : ___ am or pm	Date Report Written:___/___/___

Name of Injured:___________________________________ M___ F___ Age_____ ID# __________________
			Last		First		M.I.
Local Address:_____________________________________________________________________________
		Street Address (apt. #)		City			State	Zip	Phone
Perm. Address:_____________________________________________________________________________
		Street Address (apt. #)			City			State		Zip
Insurance Carrier____________________________Policy Number:___________________________________

Location of the accident (Be specific to the area within the room, diagram it on the back if needed):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Names of Witnesses, Addresses, Phone #’s, email (if provided)
1. ________________________________________________________________________________________
2. ________________________________________________________________________________________
3. ________________________________________________________________________________________

Details of the Accident (Be specific, the injured was doing... what was going on, who was involved.  Use back if necessary.)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Type of Injury:_____________________________________________________________________________
__________________________________________________________________________________________

Treatment (First Aid rendered): ________________________________________________________________
__________________________________________________________________________________________

Was Public Safety called?	Yes___ No___	Was Family Notified?		Yes___ No___
Referred to Health Center?	Yes___ No___	Transported to Hospital?	Yes___ No___
Transported by whom:____________________________________ Ambulance arrival time: _______________
Who called the Ambulance & at what time: ___________________ Ambulance departure time: ____________
Name of Doctor: ____________________________	Injured’s personal Doctor?  Yes___ No___

**Note to instructor: Public Safety must be called as soon as reasonably and safely possible.**

Form Filled Out by: ______________________________________________________ Date _______________
					Name/Position

Reviewed by Supervisor: __________________________________________________ Date________________
Jan. 2003 rev.

Physical Education Accident Report Form - Idaho State University
(continuation)

Location of the Accident: ______________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Diagram:

Details of the Accident: _______________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Additional Comments: ________________________________________________________________________