Injury Report
Last Modified : 05.05.2008

 

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George P. Gibbs, Inc. Injury Report Form               

Please complete and contact Mr. David Despres (978) 422-6915

Injured Person Information

Name: 

Phone Number:   (978)

Injury Information

Date (dd-mmm-yy):

Time (hh:mm):

Location of the Incident (circle one):   Major League field,  Minor League field, 

                                                      Redstone fields,  Muddy Pond field,

                                                      Other (please specify if other)

 

Detailed Description of the incident as much as possible:

 

 

 

 

 

Preliminary estimation of the extent of injuries:

 

 

 

 

 

Person Reporting Injury

Name:

Phone Number: (978)

 

                                                                                                                                                                                   

To be filled out by the Safety Officer

 

Within 48 hours of receiving the incident report, the Safety Officer will contact the injured party or the party's parents.

Report Received by Safety Officer (dd-mmm-yy):

Information received verified on date (dd-mmm-yy):

Other information deemed necessary:

 

 

 

 

Status of the injured party:

 

 

 

 

 

George P. Gibbs Jr. Little League © 2008