INCIDENT REPORT – Fusion Softball

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INCIDENT REPORTchristy conrad2023-05-25T10:41:19-04:00

INCIDENT REPORT

Report must be complete and submitted within 24 hours of the incident.

Step 1 of 4

25%

Date of the Incident*
MM slash DD slash YYYY
Time of the Incident*

: Hours

Minutes

AM/PM
Reason for report*
- Injury
- Conduct
- Other
Sport*
- Baseball
- Softball
Person Incident Report Issued On*
First Last
IFE Team or Organization person represents*
Other
Specify what organization the person represents if other than IFE.
Position*
- Player
- Coach
- Official
- Spectator
Male/Female*
- Male
- Female
Age*
Please enter a number from 1 to 100.
Event Type*
- Practice
- Game
- Other
Event Location*

Player's Address
Street Address Address Line 2 City State ZIP Code
Parent/Legal Guardian Name
First Last
Parent/Legal Guardian Address (if different from player)
Street Address Address Line 2 City State ZIP Code
Coach Name
First Last

Description of event being reported*
Who responded to the incident?*
Was First Aid treatment provided?*
- Yes
- No
If yes, who provided First Aid treatment?
First Last
Was medical treatment beyond First Aid treatment provided?*
- Yes
- No
If yes, where and who was the treating physician?
Treating physician
First Last
Describe the care provided

Was a parent/legal guardian contacted?*
- Yes
- No
- Attempted but unable to reach
Person Contacted
First Last
Witnesses
Name and phone number
Verification Statement*
Verification Statement
I verify that this report is true and correct to the best of my knowledge.
Signature of person completing this incident report.*
Typing my name below is my electronic signature, I verify that this report is true and correct to the best of my knowledge.
First Last
Email*
Date*
MM slash DD slash YYYY

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