Accident and Injury Report Form for ______________________ Dojo
Date of Injury:
Name of injured:
Instructor on duty:
Name of injured: _________________________________________
Home phone: __________________ Work phone: __________________
Category: Student____ Staff____ Faculty____ Visitor_____ Other_____
If Student, indicate enrollment: Beginner Class____ Intermediate____
STATEMENT OF ACCIDENT / INJURY / INCIDENT
Date of Incident: __________________ Time: __________________a.m./ p.m.
Location of Incident: _________________________________________________
Type of Injury: (e.g. fracture, dislocation) _________________________________________________
Description of Incident/ Injury; how did it occur? (Provide detailed information):
Name of person rendering treatment, if any: _________________________________________
Action taken, First Aid administered (Provide detailed information):
Was further Medical Assistance or Hospitalization required? Describe:
What preventive measures can and will be taken to avoid reoccurrence of this accident or injury?
The undersigned agree to the accuracy of this report and the preventive measures.
Class Instructor's signature: ______________________________ Date: ________________
Injured Party's signature: ______________________________ Date: ________________
Reviewed by Chief Instructor
Signature: ______________________________ Date: ________________