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Incident/Injury Tracking Report
League Name: _____________________________ League ID: ____ - ___ - ____ Incident Date: __________
Field Name/Location: ________________________________________________ Incident Time: __________
Injured Persons Name: ______________________________________ Date of Birth: ___________________
Address: __________________________________________________ Age: ________ Sex: r Male r Female
City: ____________________________State ________ ZIP: ________ Home Phone: ( ) _____________
Parents Name (If Player): ____________________________________ Work Phone: ( ) _______________
Parents Address (If Different): _________________________________ City ___________________________
Incident occurred while participating in:
A) ( Baseball ( T-Ball ( Minor-C ( Minor-B ( Minor- A ( Majors ( BabeRuth
B) ( Tryout ( Practice (Game ( Tournament ( Special Event ( Travel to ( Travel from
C) ( Other (Describe): ____________________________________
Position/Role of person(s) involved in incident:
D) ( Batter ( Baserunner ( Pitcher ( Catcher ( 1st Base ( 2nd ( 3rd ( Short Stop ( Left Field
( Center (Right ( Dugout ( Umpire ( Coach/Manager ( Spectator ( Volunteer ( Other: _____________
Type of injury: _____________________________________________________________________________
_________________________________________________________________________________________
Was first aid required? ( Yes ( No If yes, what:________________________________________________
Was professional medical treatment required? ( Yes ( No If yes, what: ____________________________
(If yes, the player must present a non-restrictive medical release prior to being allowed in a game or practice.)
Type of incident and location:
A) On Primary Playing Field
Base Path: ( Running ( Sliding
Hit by Ball: ( Pitched ( Thrown ( Batted
Collision with: ( Player ( Structure
( Grounds Defect
( Other:_________________________B) Adjacent to Playing Field
( Seating Area ( Parking Area
C) Concession Area
( Volunteer Worker
(Customer/BystanderD) Off Ball Field
Travel: ( Car ( Bike ( Walking
( League Activity
( Other: _________________
Please give a short description of incident: ____________________________________________________
_________________________________________________________________________________________
Could this Injury/accident been avoided? How: __________________________________________________
_________________________________________________________________________________________
This form is for Little League purposes only. This form should be used to report all injuries, near misses, safety hazards and unsafe practices. When an injury occurs obtain as much information as possible.
Prepared By/Position: ____________________________________ Phone Number: (_____) _____________
Signature: _____________________________________________ Date: _____________________________
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