Old Dominion Girls Softball League

Accident / Incident Report

 

Injured person:

q       Player

q       Coach

q       Umpire

q       Other: ________________________

Name of Injured Person:

 

1.       Date of Accident:

 

2.       Location / Field:

Time of Accident:

3.       Home team name:                                                             Manager/Coach:

 

4.       Visiting team name:                                                           Manager/Coach:

 

5.       Umpire's name:

 

6.       Describe how accident/injury occurred:

 

 

 

 

 

 

 

7.       Describe type of injury that occurred as a result of the above accident:

 

 

 

8.       Describe what actions were taken as a result of the injury (example: ice applied, bandaged, etc.)

 

 

 

9.       Was the injured taken to the hospital as a result of this accident?

 

q       Yes

q       No

10. If this was a player injury, was the player's parents, guardians, or other responsible party at the field at the time of

     the injury?

q       Yes

q       No

     If yes, provide name:

phone #:

 

11.   Optional:  Please list any other witnesses and their pertinent information:

 

Name:___________________________________________________   phone #: ____________________________

 

Name:___________________________________________________   phone #: ____________________________

 

Name:___________________________________________________   phone #: ____________________________

 

 

Home Team Manager/Coach Signature: _______________________________   Phone: ________________

 

Visiting Manager/Coach Signature: ___________________________________    Phone: ________________

 

Umpire Signature: ________________________________________________     Phone: ________________

 

 

The Injured Party's Manager/Coach is responsible for completing this form to the best of his/her ability.  This form is REQUIRED for any person who goes to the hospital as a result of an accident/injury; and is recommended to be completed for any person who is unable to continue to play in a game as a result of an accident/injury.  Forward this form to your ODGSL Division Commissioner within 48 hours of any accident/injury.  ODGSL has secondary insurance coverage.  A separate claims form is required and may be obtained from your ODGSL association representative.  All claims must be processed by the injured's primary insurance coverage FIRST, and all policies and procedures must be followed according to their primary insurance.