For Local League Use Only
A Safety Awareness Program’s
Incident/Injury Tracking Report
Activities/Reporting
03431822
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: _____________________________