Tuesday, 10 April 2012 19:38

GYFL Injury Reporting Form

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Grassroots Youth Football League Injury Reporting Form

 

 

Date: ____________ Time: _______ a.m. p.m.

 

Name: __________________________Age: ______

Position Played at time of Injury: _______________

Injury Occurred at:

 Game   1st QTR   2nd QTR   3rd QTR   4th QTR

 Practice  

 Strength and Conditioning Session

     1st 30 min   2nd 30 min   3rd 30 min   4th 30 min

Field Type:  Natural Grass    Turf

INJURY ASSESSMENT

Body Part Injured: _________________________

     *Circle area of injury/pain*

 

 

 

 

 

 

Athlete Pain Scale: 0 1   2   3   4     5   6   7     8   9   10    

(0 = no pain, 10 = agony)

Is there:    Swelling    Redness      Deformity  

 Limited range of motion compared to other side

Similar prior injury?      Yes    No    

 

If head/neck injury:

   Head position during contact:

      Up    Down      Unknown

   Part of Head/Helmet where initial contact made:  

      Front  Top  Back    Right    Left  

      Unknown

Signs: dazed, confused, forgets, moves clumsily, mentally slow, answers questions slowly or slurs speech, unconscious, behavior/personality change

Symptoms: headache, nausea, balance problems, dizziness, fuzzy vision, sensitivity to light, sluggish, foggy, confusion, memory loss (of events prior to and/or before hit)

Football Helmet Manuf. _____________________

 Old    New      Reconditioned    NOCSAE

Type of Injury:         

 Skin (abrasion, cut, laceration)

 Bone (possible broken bone)

 Soft Tissue (muscle/tendon/ligament)

 Dislocation (joint injury)

 Concussion

 Not sure  

Description of how injury occurred:

 Fall      Collision

 Other – see below

 Not sure  

_________________________________________

Able to walk off field?  Yes    No  

     If no, how was athlete removed field?

      Stretcher    Human crutch (1 person)  

      Human crutch (2 persons)

INITIAL INJURY MANAGEMENT

9-1-1 called

      Athlete transported to hospital            

      Athlete treated by EMS at scene

 Removed from practice for: _____ min. and returned to play

 Removed for remainder of practice  

 

Applied:  Splint    Tape    Ice      Compression    Bandage    Other: ________________________  

Was parent/guardian informed?  Yes    No

     Name: __________________________________

     Phone #: ________________________________

 

 

NAME OF PERSON MANAGING THIS INJURY

_____________________________________          ________________________________________

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