Date of Injury:

Name of injured:

Instructor on duty:

Name of injured: _________________________________________
Address: _________________________________________________
_________________________________________________________
Home phone: __________________ Work phone: __________________

Category: Student____ Staff____ Faculty____ Visitor_____ Other_____
If Student, indicate enrollment: Beginner Class____ Intermediate____

Branch dojo__________________

Date of Incident: __________________ Time: __________________a.m./ p.m.
Location of Incident: _________________________________________________
Type of Injury: (e.g. fracture, dislocation) _________________________________________________
Description of Incident/ Injury; how did it occur? (Provide detailed information):

Name of person rendering treatment, if any: _________________________________________

Action taken, First Aid administered (Provide detailed information):

Was further Medical Assistance or Hospitalization required? Describe:

What preventive measures can and will be taken to avoid reoccurrence of this accident or injury?

The undersigned agree to the accuracy of this report and the preventive measures.

Class Instructor's signature: ______________________________ Date: ________________

Injured Party's signature: ______________________________ Date: ________________