Skating Rink Injury Report Form

• Name

• Date of Birth

• Address

• Phone Number

• Gender

  Male

  Female

  Gender neutral

  Prefer not to say

• Prepared by

• Conducted on

  Date

• Location

Type of Activity at Time of Injury

• Training e.g warm up / cool down?

  Yes

  No

  N/A

  Unsure

• Skating on Skating Rink Floor?

  Yes

  No

  N/A

  Unsure

• Skating on Carpet Area?

  Yes

  No

  N/A

  Unsure

• Skating in Party Room Area?

  Yes

  No

  N/A

  Unsure

• Walking on the Carpet Area?

  Yes

  No

  N/A

  Unsure

• Toilet Area?

  Yes

  No

  N/A

  Unsure

Reason for Presentation to Staff

• New Injury?

  Yes

  No

  N/A

  Unsure

• Aggravated Injury?

  Yes

  No

  N/A

  Unsure

• Recurrent Injury?

  Yes

  No

  N/A

  Unsure

• Illness?

  Yes

  No

  N/A

  Unsure

• Other?

  Yes

  No

  N/A

  Unsure

Body parts Injured

• Head / Eye's / Ear's / Mouth?

  Yes

  No

  N/A

  Unsure

• Neck?

  Yes

  No

  N/A

  Unsure

• Upper Back?

  Yes

  No

  N/A

  Unsure

• Lower Back?

  Yes

  No

  N/A

  Unsure

• Sholder's?

  Yes

  No

  N/A

  Unsure

• Left Arm / Elbow?

  Yes

  No

  N/A

  Unsure

• Left Wrist / Hand / Fingers?

  Yes

  No

  N/A

  Unsure

• Right Arm / Elbow?

  Yes

  No

  N/A

  Unsure

• Right Wrist / Hand / Fingers?

  Yes

  No

  N/A

  Unsure

• Waist / Hip's?

  Yes

  No

  N/A

  Unsure

• Left Leg / Knee?

  Yes

  No

  N/A

  Unsure

• Left Foot / Toes?

  Yes

  No

  N/A

  Unsure

Nature of Injury / Illness

• Impacted Injury

  Yes

  No

  N/A

  Unsure

• Bruise / Contusion

  Yes

  No

  N/A

  Unsure

• Cardiac Problem

  Yes

  No

  N/A

  Unsure

• Cold / Flu

  Yes

  No

  N/A

  Unsure

• Concussion

  Yes

  No

  N/A

  Unsure

• Dislocation / Subluxation

  Yes

  No

  N/A

  Unsure

• Fracture

  Yes

  No

  N/A

  Unsure

• Inflammation / Swelling

  Yes

  No

  N/A

  Unsure

• Loss of Consciousness

  Yes

  No

  N/A

  Unsure

• Overuse Injury

  Yes

  No

  N/A

  Unsure

• Respiratory Problem

  Yes

  No

  N/A

  Unsure

• Skin Injury e.g. graze / cuts / blisters

  Yes

  No

  N/A

  Unsure

• Sprains e.g. Ligament tears

  Yes

  No

  N/A

  Unsure

• Sprains e.g. Muscle tears

  Yes

  No

  N/A

  Unsure

• Unspecified Medical Condition

• Other

Cause of Injury

• Collision with Fixed Object e.g Walls

  Yes

  No

  N/A

  Unsure

• Collision with other skater

  Yes

  No

  N/A

  Unsure

• Fall from heights / awkward landing e.g. sitting on wall / moving around sitting area steps

  Yes

  No

  N/A

  Unsure

• Jumping

  Yes

  No

  N/A

  Unsure

• Overexertion

  Yes

  No

  N/A

  Unsure

• Overuse

  Yes

  No

  N/A

  Unsure

• Slip / Trips / Falls / Stumbles

  Yes

  No

  N/A

  Unsure

• Struck by Object

  Yes

  No

  N/A

  Unsure

• Struck by Other Skater

  Yes

  No

  N/A

  Unsure

• Temperature related

• Other

Explain how the incident / injury occurred

• In your our words, explain how the incident / injury occurred

Contributing Factors

• Were there any contributing factors to the incident / injury? e.g. Unsuitable footwear, Skating Rink surface, equipment or foul play

Protective equipment

• Was protective equipment worn on the injured body part?

  Yes

  No

  N/A

  Unsure

• Was protective equipment available to be used free of charge?

  Yes

  No

  N/A

  Unsure

Action Taken

• None taken by injured person

  Yes

  No

  N/A

  Unsure

• Iced

  Yes

  No

  N/A

  Unsure

• CRP

  Yes

  No

  N/A

  Unsure

• Dressing

  Yes

  No

  N/A

  Unsure

• Immobilization

  Yes

  No

  N/A

  Unsure

• RICER

  Yes

  No

  N/A

  Unsure

• Sling / Splint

  Yes

  No

  N/A

  Unsure

• Strapping / Taped.

  Yes

  No

  N/A

  Unsure

• Own transport to hospital.

  Yes

  No

  N/A

  Unsure

• Ambulance called.

  Yes

  No

  N/A

  Unsure

Advice Given

• None.

  Yes

  No

  N/A

  Unsure

• Advised given that they seek medical attention ASAP.

  Yes

  No

  N/A

  Unsure

NOTICE. All injured person's are advised to seek medical attention immediately.

• Did the injured person understand the notice?

  Yes

  No

  N/A

  Unsure