Date: Event:
Sponsoring Chapter Name and Address:
Contact Name :
Phone: Fax: Email:

Injured Party:
       Name:
      Address:
      City: State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:
      Phone:
      Name of Parent/Guardian (If minor)

Type of Accident: Bodily Injury Property Damage Other

Body Part(s):

Condition (Laceration, Concussion, Sprain, Fracture, etc.):

Any Equipment involved in Accident? Yes No If so, what kind?

*Photographs of equipment involved in the accident must be provided to Disabled Sports USA

Time & Location of Injury:
Date:        Time: am pm
Location:
Function of Injured Party: Participant Volunteer Spectator Official Other

Name/Address/Phone Number of Witnesses (you may wish to attach signed statements)
1.
2.
3.

Occurrence Description:
Describe the sequence of activity in detail including what the (injured) person was doing at the time (be certain to include, when,
where, what and any special circumstances involved):

What occurred? (Specify location including location of injured and witnesses, use diagram to locate persons/objects):

Emergency Procedures followed at time of incident/accident:
By Whom?

Medical Report of Accident:
Who Was Notified? By Writing Phone Other
By Whom?
Where was treatment given? On Accident Site Only By Whom?
         EMT Physician Trainer Other
        Treatment Provided
        Off Site By Whom?
        Doctor’s Office Hospital Other
        Treatment Provided
        Was injured retained overnight in hospital? Yes No    If so, which?
        Date Released from Hospital:
        Released to:

Comments:

Print Name/Position:

Signature ____________________________________________________ Date

Complete Immediately and Email to: dsusa@dsusa.org