Injury Report (St. Catharines CYO Hurricanes)
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Injury Report
Please fill out all information. This form will be sent automatically to the Director of Risk, the President and the Secretary. It is imperative that any injury be documented in a timely fashion. Only when an injury is documented can we properly investigate and appropriately follow up.
If the injury occurred during a league or team sanctioned event, you must also fill in the
ALLIANCE INJURY REPORT FORM
. This form is to be filled in by a physician and mailed to the address located at the bottom of the form.
I understand that I must ALSO fill in the OHF injury report and send it to the ALLIANCE
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Location of incident
Date and time injury occurred
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Arena/Location where the injury occurred
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Person Injured
Name of person injured
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Division
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Minor Atom
Atom
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Peewee
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Team Trainer
Name of Team Trainer
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Trainer's phone number
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Example: ###-###-####
Trainer's Email
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Example:
[email protected]
Nature of Injury
Is the injury a possible concussion?
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Yes
No
If YES, Hockey Canada concussion protocols must be followed.
Head
throat
eye area
mouth/dental
face
skull
Check all that apply
Back/Neck
neck
upper back
lower back
Check All That Apply
Core/Trunk
ribs
chest
abdomen
Check all that apply
Pelvis
left hip
right hip
groin
Check all that apply
Arm
left shoulder
left elbow
left upper arm
left hand/finger
left forearm/wrist
left collarbone
right shoulder
right elbow
right upper arm
right hand/finger
right forearm/wrist
right collarbone
Check all that apply
Foot
left ankle
left toe
right ankle
right toe
Check All That Apply
Leg
left thigh
left knee
left shin
right thigh
right knee
right shin
Check All That Apply
Other area/injury
Injury Incident Report
Was the person injured sent to hospital or urgent care?
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No
Yes, by car
Yes, by ambulance
Describe how the injury happened
Email confirmation
Email address to receive copy of submission
Enter your email to receive a copy of this report.
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Mon Jan 18, 2021
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Printed from hurricaneshockey.ca on Monday, January 18, 2021 at 4:54 AM
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