BLOMHA REP & SELECT preliminary injury report form (BLOMHA)

BLOMHA REP & SELECT preliminary injury report form

Please fill out this form immediately. It's imperative that it's completed ASAP (within hours of the injury). It is sent directly to the Dir. of Risk Management who will connect with the player's family to check in and discuss if further steps are necessary. Please ensure you also fill out a Hockey Canada Injury Report form within 30 days where necessary. That form is found in the Trainer Resources library. ALL HEAD INJURIES OR SUSPECTED HEAD INJRURIES OF ANY KIND REQUIRE A RETURN TO PLAY FORM. The Dir. of Risk Management can complete these forms. That form is found in the Trainer Resources library. An injury report is also required.

Player first and last name^*

Required

What body part(s) was injured?^*

Required

Date incident occurred^*

Required

How did the player(s) become injured?^*

Required

Be concise. ie: went into the boards and hit their head, twisted their leg when they fell, etc.

Best family contact for player^*

Required

Parent/guardian's name and relationship

Phone number for this parent/guardian^*

Required

Email for this parent/guardian^*

Required

Email address of the person filling out this form^*

Required

Should only be a certififed Team Trainer or Team Manager

I will submit a Hockey Canada Injury report (where necessary) to BLOMHA within 30 days of the injury being reported via this form.

I will. ^*

BLOMHA REP & SELECT preliminary injury report form (BLOMHA)

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