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Club Sports Injury Reporting
Introduction
Important - review before starting
This form is intended for reporting purposes only. We do not diagnose injuries, nor are clubs expected to treat an injury/situation beyond the scope of basic first aid practices.
Club members are welcome to seek advisement from athletic training personnel, provided the trainers are present to cover the club-specific event. Athletic trainers not appointed to a club-specific event may not be seen.
Club members may be directed to University Health & Counseling Services on the UW-Whitewater campus.
Additional questions and/or concerns may be directed to Club Sports administrative staff.
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General Information - part one
Club Name
*
-
Badminton
Baseball
Basketball, Men
Basketball, Women
Billiards
Bowling, Men
Boxing
Brazilian Jiu Jitsu
Cycling
Disc Golf
Ducks Unlimited
Esports
Fencing
Fishing
FitWell
Golf
Karate/Warhawk Martial Arts
Lacrosse, Men
Lacrosse, Women
Officials Association
Outdoor Adventure
Pickleball
Rugby, Men
Rugby, Women
Running
Ski & Snowboard
Soccer, Men
Soccer, Women
Softball
Table Tennis
Tennis
Ultimate Frisbee, Men
Volleyball, Men
Volleyball, Women
Warhawk Barbell Club
Water Polo
Whitewater Cornhole
Club Not Listed
Additional instructions for the previous question.
Select from the dropdown menu
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Club Name Follow-Up
Sorry your club was not listed. Please type the club name in the space provided.
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General Information - part two
YOUR Name (First and Last)
*
YOUR Phone Number
Additional instructions for the previous question.
Enter in 123-456-7890 Format
Are you self-reporting this suspected injury?
*
Yes – the suspected injury happened to me
No – the suspected injury happened to someone else
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Person Sustaining Suspected Injury
Name of Person Sustaining Suspected Injury (First and Last)
*
Additional instructions for the previous question.
No Nicknames; please do your best to use the person’s given name, as it should appear on their Member Information & Waiver Form
Person's Phone Number
*
Additional instructions for the previous question.
Please enter in 123-456-7890 format
Affiliated Institution - please select the institution as it applies to the injured person
*
UW-Whitewater (Main Campus)
UW-Whitewater (Rock County Campus)
Visiting/Other Institution
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Visiting/Other Institution
Name of Visiting/Other Institution(s)
*
Additional instructions for the previous question.
Type in the space provided
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General Information - part three
Date of Injury
*
Additional instructions for the previous question.
Select the date from the calendar widget
Approximate Time of Injury
*
Additional instructions for the previous question.
Please specify AM/PM
Type of Event
*
-
Practice
Competition/Event
Other - specify when prompted
Additional instructions for the previous question.
Select from the dropdown menu
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Type of Event Specified
Specify type of event here
*
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Geographic Location
Where did this injury occur? Select all that apply
*
On the Main UW-Whitewater Campus
Away from the Main UW-Whitewater Campus
Disc Golf Course
Esker 108
Intramural Fields
Kachel Fieldhouse – single court
Kachel Fieldhouse – multiple courts
Miller Stadium
Perkins Stadium
Roseman Gym
Rugby Pitch
Sand Volleyball Pits
Soccer Field – Fieldhouse Field
Soccer Field – Schwager Drive Field
Soccer Field – Varsity Practice Field
University Center
van Steenderen Softball Diamond
Warhawk Tennis Courts
Williams Center Gym 1 (Kachel Gymnasium)
Williams Center, Gym 2 (Wrestling)
Williams Center, Gym 3 (Gymnastics)
Williams Center, Gym 4 (Russell Arena)
Williams Center Weight Room
Other/Not Listed
Additional instructions for the previous question.
Provide additional comments as necessary, especially for answers of "Other/Not Listed"
Comments:
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Nature of Suspected Injury
What is the nature of the suspected injury? Select all that apply.
*
Allergic Reaction
Bite or Sting
Blood Sugar Related
Bone Injury
Break
Bump or Bruise
Burn
Cardiac
Choking
Cut
Dehydration/Malnutrition
Difficulty Breathing
Dislocation
Electrical Shock
Head/Concussion
Joint Injury
Laceration or Abrasion
Muscle Injury
Poisoning
Puncture
Sprain
Strain
Swelling
Other/Not Listed
Additional instructions for the previous question.
Please describe "Other/Not Listed" or any other pertinent information in the space provided. If you are prompted that a response is required, please type "N/A."
Comments:
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Location of Suspected Injury
What side of the body was involved in this suspected injury?
*
Left
Right
Middle
N/A
What body part(s) is/are involved with this suspected injury? Select all that apply; listed alphabetically
*
Abdomen
Ankle
Arm
Back
Calf
Chest
Chin
Ear
Elbow
Eye
Face
Finger(s)
Foot
Hand
Head
Hip
Knee
Leg
Mouth
Neck
Nose
Scalp
Shoulder
Teeth
Thigh
Wrist
Other/Not Listed
Additional instructions for the previous question.
Please describe "Other/Not Listed" or any other pertinent information in the space provided. If you are prompted that a response is required, please type "N/A."
Comments:
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Follow-Up Items - part one
Was first aid offered?
*
Yes
No
Unsure
Was first aid refused?
*
Yes
No
Unsure
Athletic training services were on-site at this event
*
Yes
No
Unsure
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Follow-Up Items - part two
What was the type(s) of first aid that was provided? Select all that apply; listed alphabetically
*
AED
Bandage(s)
Choking Assistance
CPR
Epipen
Gauze
Glucose Pakcet(s)
Ice
Nose Plug(s)
Sling
Tape
Tourniquet
Wrap
Other/Not Listed
Additional instructions for the previous question.
Please describe "Other/Not Listed" or any other pertinent information in the space provided. If you are prompted that a response is required, please type "N/A."
Comments:
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Follow-Up Items - part three
Please, to the best of your knowledge, describe how this suspected injury occurred. Be as specific as possible
*
After the suspected injury was recognized and/or treated on-site, what happened next? Select all that apply
*
Individual remained on-site but did not return to action
Individual remained on-site and returned to action (no advisement was received; at own discretion)
Individual remained on-site and returned to action (received clearance from applicable/affiliated event personnel)
Individual remained on-site and returned to action (despite advisement to refrain from participating further)
EMS/Ambulance service was called and injured individual left with them to seek medical attention
EMS/Ambulance service was called and injured individual left with someone else to seek medical attention
EMS/Ambulance service was called and injured individual remained on-site following consultation
EMS/Ambulance service was not called
Injured individual decided to seek medical attention and left the event
Injured individual decided to seek medical attention following the event
Other/Not Listed
Additional instructions for the previous question.
Please describe "Other/Not Listed" or any other pertinent information in the space provided. If you are prompted that a response is required, please type "N/A."
Comments:
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Conclusion
This is the final section of this form. We thank you for your time in completing this report.
Optional: Is there anything else about this situation Club Sports administrative staff should be made aware of?
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