Speed Skating Manitoba - SSM Injury Report

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SSM Injury Report

Respondent*

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First name *

Last name *

Email *

Mobile *

Date and approximate time of injury *

×

Facility *

Facility

Event

Event

Name of individual injured *

Name of individual injured

When did the injury occur? *

Practice Competition Warm-up Other x Clear

If other, please specify

What body part was injured? *

What body part was injured? Head Face Neck Back Abdomen Shoulder Upper arm Elbow Lower arm Wrist Hand Hip Upper leg Knee Lower leg Ankle Foot Other

If other, please specify

Type of injury *

Type of injury Concussion Laceration Bruise Broken bone Dislocation Sprain Muscle strain Separation Don't know Other

If other, please specify

Describe how the injury happened *

Describe how the injury happened

Was on-site care provided? *

Yes No x Clear

Provide more details (if available)

Provide more details (if available)

Did the person return to participation after injury? *

Yes No x Clear

Was an ambulance called? *

Yes No x Clear

Provide more details (if available)

Provide more details (if available)

Other individual(s) involved in accident or injury care

Other individual(s) involved in accident or injury care

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