Xavier University Recreational Sports Department - Accident Report - Immediate Actions and Follow-Up

Sep 29, 2026

Xavier University Recreational Sports Department Accident Report form collects complete incident information, including report and accident dates, time of day, injured person personal data, and injury status (student, employee, guest, member, or other). It records accident location and program participation, describes how the injury occurred, identifies injured body parts, and documents immediate action, first responder details, and care provided. It also includes further care options, witness contact, signatures, and required filing timeline within 24 hours, followed by review and follow-up call log.

LanguageEnglish

CategoryHealthcare

FormatDOCX

Pages2

Reading Time5 min

AccessFree to download

Accident Report Information

Personal Data

Details of Accident

Injury Description and Immediate Action

Further Care and Acknowledgement

Accident Report Follow-Up

XAVIER UNIVERSITY RECREATIONAL SPORTS DEPARTMENT ACCIDENT REPORT Date of Report___________ Date of Accident___________ Time of Accident_________ AM or PM PERSONAL DATA Name of Injured_________________________________ XU I.D. Number___________________________ Local Address_____________________________________________________________________________ Local Phone________________________________ Gender: Male / Female Date of Birth_______________________________ Status of Injured: ____Student ____Employee ____Guest ____Member ____Other (Please Specify) ________________________________________ Injured Person’s Nearest Relative (Name/Address/Phone #) ______________________________________ DETAILS OF ACCIDENT Location of Accident: ( Armory ( Balance Studio ( Basketball Courts ( Cardio Floor ( Fieldhouse ( 2nd floor alcove ( 3rd floor alcove ( Locker Room ( Park Field ( Persist Studio ( Pool ( Sand Volleyball Courts ( Strength & Weight floor ( Sherman Field ( Soccer Complex ( Tennis Courts ( Track ( Transform Studio ( Other: Program Participated In: ____Intramural Sports ____Club Sports ____Special Event ____Informal Rec. ____Rental ____Fitness Class ____Other (Please Specify) __________________________________________ HOW DID INJURY OCCUR? ___Collision w/Obstacle ____Collision w/Participant ____Collision w/Playing Surface ____Equipment Related ____Non-Contact ____Unknown ____Other (Please Specify) __________________________________________________________________ DESCRIBE MORE SPECIFICALLY: ______ PART OF BODY INJURED Check if Applicable: ____Right ____Left ____Face ____Eye ____Nose ____Ear ____Mouth ____Neck ____Back ____Shoulder ____Torso ____Arm ____Hand ____Finger ____Wrist ____Hip ____Groin ____Leg ____Knee ____Ankle ____Foot ____Toe ____Other ADDITIONAL DETAILS OF INJURY: ______ IMMEDIATE ACTION TAKEN Name of First Responder ____________________________________________ Staff Position ___________________________________ Phone # ____________________________ DETAIL CARE PROVIDED: FURTHER CARE ____Went home on own ____Self/Friend to Hospital ____Ambulance to Hospital ____Friend took home ____Self/Friend to Health Center ____Left Area, No Information Witness _____________________________ Phone_______________ Email________________________ Acknowledgement of Care (Injured Signature) _______________________________ Date_____________ Refusal of Service (Injured Signature) ______________________________________ Date_____________ Signature of Person Completing Report ____________________________________ Date_____________ THIS REPORT MUST BE FILED WITH THE ASSISTANT DIRECTOR OF AQUATICS AND RISK MANAGEMENT WITHIN 24 HOURS OF ACCIDENT. ACCIDENT REPORT FOLLOW-UP REPORT REVIEWED BY (PLEASE INITIAL): ____Asst. Director ____Manager Date Reviewed _________ Follow-Up Report on Injured Person’s Progress - Call Log: Attempt #1 Date_____________ Time________ Caller Signature___________________________ Attempt #2 Date_____________ Time________ Caller Signature___________________________ Attempt #3 Date_____________ Time________ Caller Signature___________________________ STATUS OF INJURED PERSON: ____Injured participant is fine now. No complications. ____The accident was serious enough to warrant additional medical attention. The injury was diagnosed as____________________________________________________________________________ ____Unknown Submitted by____________________________ Date_____________ Signature_______________________ Medical Care: ____Hospital ____EMS ____Private Physician ____None ____Other FINAL REVIEW BY: ____Assistant Director ____Manager Date ____________

FAQs

What information is required at the time of reporting an accident?

The form requests report date, accident date, time of accident, injured person personal data, accident location, program participated in, and how the injury occurred.

How should the injury and affected body parts be documented?

The form requires selecting applicable body parts (including side, such as right/left) and adding additional injury details, along with further care information.

What follow-up steps are included after the accident report is filed?

It requires review by the assistant director or manager, a follow-up progress section with call log attempts and contact details, and final review with dates and initials/signatures.

Sep 29, 2026

Uploaded by Emma Wilson