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Accident___________ Time of Accident_________ AM or PM\nPERSONAL DATA\nName of Injured_________________________________\tXU I.D. Number___________________________\nLocal Address_____________________________________________________________________________\nLocal Phone________________________________\tGender:\tMale   /   Female\nDate of Birth_______________________________\nStatus of Injured:\t____Student\t____Employee\t____Guest\t____Member\n____Other (Please Specify) ________________________________________\nInjured Person’s Nearest Relative (Name/Address/Phone #) ______________________________________\nDETAILS OF ACCIDENT\nLocation of Accident:\n( Armory\n( Balance Studio\n( Basketball Courts\n( Cardio Floor\n( Fieldhouse\n( 2nd floor alcove\n( 3rd floor alcove\n( Locker Room\n( Park Field\n( Persist Studio\n( Pool\n( Sand Volleyball Courts\n( Strength & Weight floor\n( Sherman Field\n( Soccer Complex\n( Tennis Courts\n( Track\n( Transform Studio\n( Other:\nProgram Participated In:\t____Intramural Sports\t____Club Sports\t____Special Event\n____Informal Rec.\t\t____Rental\t\t____Fitness Class\n____Other (Please Specify) __________________________________________\nHOW DID INJURY OCCUR?\n___Collision w/Obstacle\t____Collision w/Participant\t\t____Collision w/Playing Surface\n____Equipment Related\t____Non-Contact\t\t\t____Unknown\n____Other (Please Specify) __________________________________________________________________\nDESCRIBE MORE SPECIFICALLY:\n______\nPART OF BODY INJURED\nCheck if Applicable:\t\t____Right\t____Left\n____Face\t____Eye\t____Nose\t____Ear\t____Mouth\t____Neck\t____Back\n____Shoulder\t____Torso\t____Arm\t____Hand\t____Finger\t____Wrist\t____Hip                      ____Groin\t____Leg\t____Knee\t____Ankle\t____Foot\t____Toe\t____Other\nADDITIONAL DETAILS OF INJURY:\n______\nIMMEDIATE ACTION TAKEN\nName of First Responder ____________________________________________\nStaff Position ___________________________________\t\tPhone # ____________________________\nDETAIL CARE PROVIDED:\nFURTHER CARE\n____Went home on own\t____Self/Friend to Hospital\t\t____Ambulance to Hospital\n____Friend took home\t____Self/Friend to Health Center\t____Left Area, No Information\nWitness _____________________________   Phone_______________\tEmail________________________\nAcknowledgement of Care (Injured Signature) _______________________________  Date_____________\nRefusal of Service (Injured Signature) ______________________________________  Date_____________\nSignature of Person Completing Report ____________________________________   Date_____________\nTHIS REPORT MUST BE FILED WITH THE ASSISTANT DIRECTOR OF AQUATICS AND RISK MANAGEMENT  WITHIN 24 HOURS OF ACCIDENT.\nACCIDENT REPORT FOLLOW-UP\nREPORT REVIEWED BY (PLEASE INITIAL):  ____Asst. Director    ____Manager     Date Reviewed _________\nFollow-Up Report on Injured Person’s Progress\t- Call Log:\nAttempt #1\tDate_____________\tTime________\tCaller Signature___________________________\nAttempt #2\tDate_____________\tTime________\tCaller Signature___________________________\nAttempt #3\tDate_____________\tTime________\tCaller Signature___________________________\nSTATUS OF INJURED PERSON:\n____Injured participant is fine now.  No complications.\n____The accident was serious enough to warrant additional medical attention.  The injury was diagnosed\nas____________________________________________________________________________\n____Unknown\nSubmitted by____________________________  Date_____________  Signature_______________________\nMedical Care:  ____Hospital\t____EMS\t____Private Physician\t____None\t____Other\nFINAL REVIEW BY:     ____Assistant Director      ____Manager      Date ____________","cbCailpbGOWrd4Oj","https://ap.wps.com/l/cbCailpbGOWrd4Oj","docx",17034,"English","# Accident Report Information\n## Personal Data\n## Details of Accident\n## Injury Description and Immediate Action\n## Further Care and Acknowledgement\n## Accident Report Follow-Up","[{\"question\":\"What information is required at the time of reporting an accident?\",\"answer\":\"The form requests report date, accident date, time of accident, injured person personal data, accident location, program participated in, and how the injury occurred.\"},{\"question\":\"How should the injury and affected body parts be documented?\",\"answer\":\"The form requires selecting applicable body parts (including side, such as right/left) and adding additional injury details, along with further care information.\"},{\"question\":\"What follow-up steps are included after the accident report is filed?\",\"answer\":\"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.\"}]","Xavier University Recreational Sports Department - Accident Report - Immediate Actions and Follow-Up | DOCX",1790650656]