Injury Report (St. Catharines CYO Hurricanes)

Print 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^*

Location of incident

Date and time injury occurred^*

Open the calendar popup.

Open the time view popup.

Arena/Location where the injury occurred^*

Person Injured

Name of person injured^*
Division^*
Minor Atom
Atom
Minor Peewee
Peewee
Minor Bantam
Bantam
Minor Midget
Midget

Team Trainer

Name of Team Trainer^*
Trainer's phone number^*

Example: ###-###-####
Trainer's Email^*

Example: [email protected]

Nature of Injury

Is the injury a possible concussion?^*
YesNo
If YES, Hockey Canada concussion protocols must be followed.
Head
throateye areamouth/dentalfaceskull
Check all that apply
Back/Neck
neckupper backlower back
Check All That Apply
Core/Trunk
ribschestabdomen
Check all that apply
Pelvis
left hipright hipgroin
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 ankleleft toeright ankleright 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