Creative Kids Place - Injury and Accident Report

Incident Report

Location: *

Mississauga West Streetsville Square One Churchill Meadows Port Credit Oakville Oakville West

Date of Incident *

Date Report Written: *

Report Written By

First name *

Last name *

Report Reviewed and Approved by (Name & position)

Type of Report *

Observation or Incident Near Miss or Injury Other

Category of Report *

Major Critical Serious Minor Very Low

Child Involved

Child's Full Name *

Child's Age

Child's Gender *

Male Female Other

The Incidence

Date of Incidence *

Time of Incidence

Specific Location of the Incidence

Other

The Cause of the Injury

Equipment involved in the incident (such as toys, playground equipment, furniture, medication)

Cause of the Injury *

Fall from a Height Pinched/Caught In Burn Sharp/Piercing Object Hit By or Bumped Into an Object Human Bite Splinter/Foreign Object

Other

Type of Injury *

Body Parts Injured *

Witness #1 to the Incident

First name

Last name

Mobile

Position at CKP

Witness #2 to the Incident

First name

Last name

Mobile

Position at CKP

When Were Parents Notified?

How Were Parents Notified?

Phone Voicemail Email In Person

Name of Parent/Guardian Notified

First name *

Last name *

Individual Experiencing Injury Information:

The injured athlete or their parent/guardian will receive a receipt of this information via email.

First name *

Last name *

Email *

Mobile *

Gender

Date of birth *

Address

City

Country

State/Province

Zip/Postal code

Other phone (home or work)

Injury Details

Injured Body Part *

Type of Suspected Injury (Select all that may apply at the time of injury) this information will be updated following a formal medical diagnosis

Bone Bruise Bruise Fracture Laceration Sprain Concussion - Please Complete Concussion Form*

Other

Side *

Right Left Both NA

Date of Injury/Accident *

Time of injury *

Please provide details on how the incident happened (include any special or unusual circumstances related to the incident): *

Action Taken

What action did you take? *

By whom (First and Last Name) *

Phone *

Describe:

Name of hospital / clinic (if applicable)

Transported by:

When was the parent informed?

Informed by:

Coach Staff Other

First and Last Name

Witnesses

Witness #1

First name

Last name

Mobile

What is their role?

Witness #2

First name

Last name

Mobile

What is their role?

Upload an image of incident

Submitted by:

Please provide contact information for the individual who filled out this form.

First name *

Last name *

Email *

Mobile

Other phone

Role

Electronic signature*

Please sign your name inside the box

Incident Report

Location: *

Date of Incident *

Date Report Written: *

Report Written By

Report Reviewed and Approved by (Name & position)

Type of Report *

Category of Report *

Child's Full Name *

Child's Age

Child's Gender *

Date of Incidence *

Time of Incidence

Specific Location of the Incidence

Other

The Cause of the Injury

Equipment involved in the incident (such as toys, playground equipment, furniture, medication)

Cause of the Injury *

Type of Injury *

Body Parts Injured *

Witness #1 to the Incident

Witness #2 to the Incident

When Were Parents Notified?

How Were Parents Notified?

Name of Parent/Guardian Notified

Individual Experiencing Injury Information:

Injured Body Part *

Type of Suspected Injury (Select all that may apply at the time of injury) *this information will be updated following a formal medical diagnosis *

Side *

Date of Injury/Accident *

Date of Injury/Accident *

Time of injury *

Please provide details on how the incident happened (include any special or unusual circumstances related to the incident): *

Action Taken

What action did you take? *

By whom (First and Last Name) *

Phone *

Describe:

Name of hospital / clinic (if applicable)

Transported by:

When was the parent informed?

Informed by:

Witness #1

What is their role?

Witness #2

What is their role?

Upload an image of incident

Submitted by:

Role

Electronic signature*

Type of Suspected Injury (Select all that may apply at the time of injury) this information will be updated following a formal medical diagnosis