PLL Preliminary Incident Report

Name of Injured:

DOB:

Gender:

Male

Female

Phone:

Parent(s) Name(s):

Address:

- Incident and Injury Information -

Date of Incident:

Time:

Field:

Short description of Incident:

Was First Aid Required? If so, what?

Yes

No No

Was Professional Medical Treatment Required? If so, What?

Yes

No 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 No

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

Yes

No No

Prepared By:

Phone:

Email: