PLL Preliminary Incident Report

Name of Injured:

DOB:

Age:

Sex:

Male

Female

Parents Name(s):

Home Phone:

Alt. Phone:

Address:

-------- Incident and Injury Information --------

Date of Incident:

Time:

AM

PM

Field:

Short description of Incident:

Was First Aid Required? If so, what?

Yes

No

Was Professional Medical Treatment Required? If so, What?

Yes

No

Type Ball:

Baseball

Softball

Team Name:

Division:

Injured person was:

Position when injured:

Type of Injury:

Injured Body Part:

Cause of Injury:

Were there any witnessess to the accident? Who/phone #?

Yes

No

Could this accident have been avoided? If so, how?

Yes

No

Prepared By:

Phone:

E-mail Address: