Gymnastics BC - GymBC Injury and Accident Report Form Updated Nov 7, 2021

Gymnastics BC Injury and Accident Report Form

Please complete this form in full (one per incident) and submit to Gymnastics BC within 48 hours of the incident. *If a concussion is suspected, please complete the GymBC Concussion Incident Report. Only currently registered Gymnastics BC members are covered by the Sport Accident Insurance Policy (birthday party, field trip, and other one-time participants are NOT covered).

Individual Experiencing Injury Information:

The injured athlete or their parent/guardian will receive a receipt of this information via email. Please use the athlete's home address instead of the club address, if possible.

First name *

Last name *

Email

Mobile *

Gender

Date of birth *

Address

City

State/Province

Zip/Postal code

Other phone (home or work)

Please Select Their GymBC Club: *

What Is Their Role? *

Gymnast Level *

Rec/Active Start Parent and Tot Rec/Active Start Preschool Age Rec (School Age) Rec (Adult) Interclub (school age) Comp (including Xcel) Coach

Other:

Years of Experience *

Supervising Coach *

Please include the first and last name of the person instructing the participant's class/program

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 *

How many minutes into training did the injury occur? *

Occasion: *

How did the incident occur? *

Approach Mount Mid-routine Spotting Dismount/Landing/Take-Off Stretching/Conditioning/Warm-Up

Other

Apparatus/Area - Select all that apply *

Situation *

Fall (slip, trip, pushed, lost balance) Over-rotated Under-rotated Missed Collison with Person Collison with Object

Other

What skill was being attempted at the time of the incident? *

What progressions were taught before the gymnast attempted the skill?

Was spotting (or other aids) used? *

What precautions were taken to prevent the incident?

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?

If it is likely that the injured party will make an insurance claim, please ensure that they receive a copy of the GameDay Sport Accident Claim Form and instructions on making claims. These are available on the GymBC website. The claim form must be submitted to Gymnastics BC within 30 days of the incident. Gymnastics BC will forward the form to GameDay Insurance. Please keep all documentation and receipts related to medical care from the incident to facilitate the claims process.

Upload an image

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

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Gymnastics BC Injury and Accident Report Form

Individual Experiencing Injury Information:

Please Select Their GymBC Club: *

What Is Their Role? *

Gymnast Level *

Years of Experience *

Supervising Coach *

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 *

Time of injury *

How many minutes into training did the injury occur? *

Occasion: *

How did the incident occur? *

Apparatus/Area - Select all that apply *

Situation *

What skill was being attempted at the time of the incident? *

What progressions were taught before the gymnast attempted the skill?

Was spotting (or other aids) used? *

What precautions were taken to prevent the incident?

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

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