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First Report of Accident

Fields in bold are required.

This accident occurred on    , 
Email a copy of this report to

Injured Person
Injured person Athlete
Coach
Employee
Spectator
Unified partner
Property owner
Other:
First name
Last name
Address
City
State
Zip code
Home phone - - x
Work phone - - x
Social security number - -
Gender female
male

Description of Accident
Type of accident Bodily injury
Property damage
Automobile
Other:
Describe how the accident occurred.
Site/event where accident occurred
Accident occurred during Training/practice
Competition
Traveling to or from a Special Olympics Minnesota event
Other:
Type of injury Severe cut with bleeding
Less serious bruise or cut
Break/fracture
Concussion
Paralysis
Fatality
Other:
Disposition Released to parent
Refusal of care
Refer to doctor
Refer to hospital or clinic
Medical attention
EMS transport
Patient requested EMS transport
Released to personal vehicle
Police
Ambulance
Report only
Other:
Sport
If "other," please identify:
Body part injured Head
Neck
Torso
Back
Hand (left)
Hand (right)
Finger (left)
Finger (right)
Elbow (left)
Elbow (right)
Shoulder (left)
Shoulder (right)
Leg (left)
Leg (right)
Knee (left)
Knee (right)
Thigh (left)
Thigh (right)
Shin (left)
Shin (right)
Toe (left)
Toe (right)
Other:

Contact Provider Information

If an athlete or underage volunteer was injured, please identify the care provider and/or responsible party.
e.g., parent, legal guardian
Provider first name
Provider last name
Provider address
Provider city
Provider state
Provider zip code
Provider phone - - x
Employer name
Employer address
Employer city
Employer state
Employer zip code
Employer phone - - x
Does the injured person have medical insurance? yes
no
If yes, insurance provided by: Injured person
Care provider/responsible party
Company
Policy
Was the parent/guardian/group home notified? yes
no
Athlete is own guardian.
If yes, please enter notification date:    , 

Witness Information

Please provide names and phone numbers of any witnesses to the accident.
Witness 1  
First name
Last name
Daytime phone - - x
Witness 2  
First name
Last name
Daytime phone - - x
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