Lacrosse Head/Face Injury Incident Report
Date of Incident
Time of Incident
Game Location
Team Name
Player Name
Player Number
Position
Coach Name
Type of Injury (select all that apply)
Concussion/Suspected Concussion
Laceration
Fracture
Bruise/Contusion
Other
Describe How Injury Occurred
Immediate Action Taken
Was Medical Personnel Present?
Yes
No
If yes, who?
Was Player Removed From Play?
Yes
No
Additional Comments
Reported By
Date Reported