Injury Data Collection Form

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Date Injury Occurred(mm/dd/yy):

Association:
 
Class:
 
Game   Practice
Exhibition   Off / Ice
Playoff   Tournament
Other : Detail  
Division:
 
Rep/Select/House:
 
Other:
 
 

Age:
   
Gender:
   
       
Team Name:
 
Arena Name:
     
Arena Town:
           

Location of Injury
Head Area     Torso   Limbs
Head   Internal   Upper Arm
Eye   Ribs Front   Elbow
Throat   Side Ribs   Lower Arm
Face   Sternum   Wrist
Dental   Spine   Finger
Neck   Back Upper   Thigh
Ear   Back Lower   Knee
Lower   Shoulder   Lower Leg
Groin   Collarbone   Ankle
Hip         Foot
Other:

          
Type of Injury
Strain   Sprain   Bruise
Fracture   Dislocation   Laceration
Concussion   Seperation      
Other : Details  

Signs
Pain   Loss of Feeling

Symptoms
Deformity   Short of Breath
Light Bleeding   Heavy Bleeding
Other : Details  

Mode of Transportation
Transported to Hospital?
Ambulance   Private Vehicle
Other : Details  

Type of Medical Care
Family Physician
Emergency Clinic
Sports Clinic
Other : Details  

Home / Away
Home   Away

Game Period:

Player Position:

Penalty
Penalty Called     Type of Penalty:
Opposing Player   Injured Player  

# Days off:
# weeks off:

Trainer
Trainer Name:
Trainers #:
Trainers Level:
Did Trainers Certification Help?   Date Completed (mm/dd/yy):

Location in facility where injury occured
Defensive Zone   Neutral
Goal Crease   Offensive
Player Bench   Penalty Box
Other : Details  

Causes of Injury
Puck   Check Behind   Skate
Stick   Collision   Fell on ice
Boards   Trip   Net
Poor Fitting Equipment   Body Check   Faulty Equipment
Other:

Comments:


This form is to be completed each time: A player is removed for the remainder of a period or game due to an injury sustained while playing hockey. (Example: A player injured in the first period but who returns to play in the second or third period would have a form filled out for them.) A player is injured during a practice, whether on or off the ice. A player is forced to leave play for a health reason that is not known. PURPOSE: This "Injury Report" is designed to provide organized hockey in Ontario with the critical information on hockey injuries that is required to permit the hockey bodies in Ontario to discuss possible changes to enhance safety in the game of hockey. Note: All player information of a personal or injury nature that is recorded on this form is considered to be confidential and is not to be used in any manner to determine a player's future ability to play the game. This form is to be completed in full by the team trainer or other team official. The information should be as complete and accurate as possible. Only one form is to be completed for each player for each injury incident that occurs. If you require assistance in completing this form, please contact the HDCO office at 416-426-7252 or toll free at 1-888-843-4326

This Injury Report Form is not meant in any way to replace or substitute for the Hockey Canada’s Accident or Serious Injury Report Forms.