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Campus Recreation
Programs - Sport Clubs - Accident Report In order to try to provide you with the easiest method of reporting an accident, please take a moment to fill out this request. Date Sport Club Submitted By Phone Name of injured First Last Student ID# Injured person cell Address Date of Injury Time of Injury Location Specific Activity/ How Injury Occurred Witnesses: Name Phone Address What did they see/hear/witness Name Phone Address What did they see/hear/witness Name Phone Address What did they see/hear/witness Specific Injury Location (upper body, right knee, ankle, etc.) Treatment Given (Be specific): Ambulance Called? Yes No Other form of transport Friend Bystander Campus Supervisor self Transported to Cutler Hospital Other Transported by: (Name's) Additional Information Back to Sports Clubs
In order to try to provide you with the easiest method of reporting an accident, please take a moment to fill out this request.
Date Sport Club Submitted By Phone
Name of injured First Last Student ID#
Injured person cell Address
Date of Injury Time of Injury Location
Specific Activity/ How Injury Occurred
Witnesses:
Name Phone Address
What did they see/hear/witness
Specific Injury Location (upper body, right knee, ankle, etc.)
Treatment Given (Be specific):
Ambulance Called? Yes No Other form of transport Friend Bystander Campus Supervisor self
Transported to Cutler Hospital Other
Transported by: (Name's)
Additional Information
Back to Sports Clubs
Campus Recreation 5797 Student Recreation and Fitness Center Orono, ME 04469-5797 Phone: (207) 581-1082 Fax: (207) 581-4898
