For Local League Use Only

A Safety Awareness Program’s Incident/Injury Tracking Report

Activities/Reporting

League Name: _____________________________ League ID: ____ - ___ - ____ Incident Date: __________ Field Name/Location: _________________________________________________ Incident Time: __________ Injured Person’s Name: ______________________________________ Date of Birth: ___________________ Address: __________________________________________________ Age: ________ Sex: ❒ Male ❒ Female City: ____________________________State ________ ZIP: ________ Home Phone: (

) _____________

Parent’s Name (If Player): ____________________________________ Work Phone: ____________

) _____________

(

Parents’ Address (If Different): _________________________________ City ___________________________ Incident occurred while participating in: A.) ❒ Baseball

❒ Softball

❒ Challenger

❒ TAD

B.) ❒ Challenger

❒ T-Ball (4-7) (5-8)

(7-11) ❒ Minor (7-12)

❒ Major (9-12)

(50/70) (11-13) ❒ Intermediate Junior (13-14)

Senior (13-16)(16-18) Big League (15-18) ❒ Junior Senior(12-14) (14-16) ❒ Big League C.) ❒ Tryout ❒ Travel to

❒ Practice

❒ Game

❒ Tournament

❒ Special Event

❒ Travel from

❒ Other (Describe): ________________________________________

Position/Role of person(s) involved in incident: D.) ❒ Batter

❒ Baserunner

❒ Pitcher

❒ Catcher

❒ First Base

❒ Second

❒ Third

❒ Short Stop

❒ Left Field

❒ Center Field

❒ Right Field

❒ 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 to being allowed in a game or practice.) Type of incident and location: A.) On Primary Playing Field ❒ Base Path: ❒ Running or ❒ Sliding ❒ Hit by Ball:

❒ Pitched or

❒ Collision with: ❒ Player or

❒ Thrown or ❒ Batted ❒ Structure

B.) Adjacent to Playing Field ❒ Seating Area ❒ Parking Area C.) Concession Area

D.) Off Ball Field ❒ Travel: ❒ Car or ❒ Bike or ❒ Walking

❒ Grounds Defect

❒ Volunteer Worker

❒ League Activity

❒ Other: ____________________________________

❒ Customer/Bystander

❒ Other: ________

Please give a short description of incident: ____________________________________________________ _________________________________________________________________________________________ Could this accident have been avoided? How: __________________________________________________ This form is for local Little League use only (should not be sent to Little League International). This document should be used to evaluate This form is for Little League purposes only, to report safety hazards, unsafe practices and/or to contribute posipotential safety hazards, unsafe practices and/or to contribute positive ideas in order to improve league safety. When an accident occurs, tive ideas in order to improve league safety. When an accident occurs, obtain as much information as possible. obtain as much information as possible. For all Accident claims or injuries that could become claims to any eligible participant under the AcFor allInsurance claims policy, or injuries could becomeNotification claims, please fill out and at turn in the official Little League Baseball cident pleasewhich complete the Accident Claim form available http://www.littleleague.org/Assets/forms_pubs/ Accident Notification Form available from your league president and send to Little League Headquarters in asap/AccidentClaimForm.pdf and send to Little League International. For all other claims to non-eligible participants under the Accident Williamsport (Attention: Dan Kirby, Risk Management Department). Also, provide your District Safety Officer with policy or claims that may result in litigation, please fill out the General Liability Claim form available here: http://www.littleleague.org/Asa copy for District files. All personal injuries should be reported to Williamsport as soon as possible. sets/forms_pubs/asap/GLClaimForm.pdf.

Prepared By/Position: ____________________________________ Signature: _____________________________________________

Phone Number: (_____) _____________ Date: _____________________________