Fairfax Little League Injury Report

(If, instead of reporting an injury, you want to forward a suggestion and/or comment
to the Safety Director, please use the  Safety Comments and Suggestions Page instead)

Injured Person's Background Information
Name:    DOB:    Male Female
Parents:    Age:    asap.gif (9548 bytes)
Address:    Home 
 Ph:  		 
City/St/Zip:    Work 
 Ph:  		 
 
Injury Information
Date of Incident:

Time of Incident:
AM PM

Place of Injury/Field Name:

Description:
 Was first aid required?  Yes  No
 If so, explain what was done:
  		 Were medical professionals required?  Yes  No
 If so, explain what was done:
 
Check applicable response in each column below:

League

Division

Team Info

Injured Person Was a:

Injury Occurred During a:
American
Dominion
National
T-Ball
Juniors
TAD 		T-Ball
A
AA
AAA
Majors
Juniors
Challenger
 Team Name:
 

 Coach's Name:
 

 Coach's Phone #
 

Player
Manager,Coach
Umpire
Official Scorekeeper
Volunteer Worker
Spectator

Practice
Scheduled Game
Special Event
Tournament
Travel To
Travel From
Tryouts
Other  

 

 

Check applicable response in each column below:

Position When Injured:

Type of Injury:

Part of Body Injured:

Cause of Injury:

 1st Base
 2nd Base
 3rd Base
 Batter
 On Bench
 Bull Pen
 Catcher
 Coaching Box
 Dugout
 Manager/Coach
 Outfield
 Pitcher
 Runner
 Scorekeeper
 Shortstop
 To/From Game
 Umpire
 Other
 Unknown
 Warming Up

Abrasion
Bites
Concussion
Contusion
Dental
Dislocation
Dismemberment
Epiphyses
Fatality
Fracture
Hematoma
Hemorrhage
Laceration
Puncture
Repture
Sprain
Sunstroke
Other
Unknown
Paralysis/Paraplegic

 
 
 Abdomen
Ankle
Arm
Back
Chest
Ear
Elbow
Eye
Face
Fatality
Finger
Foot
Hand
Head
 Hip
Knee
Leg
Lips
Mouth
Neck
Nose
Shoulder
Side
Teeth
Testicle
Wrist
Other
Unknown 		 
Batted Ball
Batting
Catching
Colliding with Person(s)
Colliding with Structure
Falling
Hit by Bat
Horseplay
Pitched Ball
Running
Sharp Object
Sliding
Tagging
Throwing
Thrown Ball
Other
Unknown

Please provide us with the following information in case we need to contact you:


                         Name:

                         Phone:

                         E-mail: