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Report of Injury In Youth Hockey - District 3 Minnesota Hockey - Season 2009-2010

Thank you for your participation in this Pilot program to determine the nature of injuries that players are incurring. It is important that you fill out the form as completely as possible.

The data is being collected and reported by the Trauma Services Department at Hennepin County Medical Center on behalf of the Minnesota Hockey Safety Committee.

This site is for youth hockey injury reports only. Other issues relating to
coaching or team problems must be directed to the local association.
Submissions that do not have a contact name and phone number will be deleted.

Instructions:
1) Complete on-line form
2) Print a copy for your records
3) Submit form via email to greg.kassmir@hcmed.org

Definition of “Injury”:
For the purposes of this form, “injury” is defined as: any medical occurrence that requires missing a game or practice or brings the player to medical attention. Please report all events that might qualify as significant

The coach or team contact is required to verify the injury reported.

Complete and Submit

Today's Date (DD/MM/YY):
Player Jersey Number:
Team Name:
Association:
Team Level:
Team Contact Name:
Team Contact Address:
Team Contact Phone:
Team Contact Email:
Date Injury Occurred (DD/MM/YY):
Date Injury Recognized (DD/MM/YY):
Location Where Injury Occurred:
If Other:
Nature of Injury:
If Other or Combination:
If the Injury is From Trauma, please choose the primary object of contact:
If Other or Combination:
Injury Classification:
Injury Diagnosis and/or Description:
Injury Treatment:
Projected Length of Time Off Sports: