Home About Meet the Staff Mission, Vision and Values Student Employment Memberships Student Recreation Advisory Council Facilities Student Recreation and Wellness Center Check In Monitor Albee Hall and Pool Rec Plex Kolf Sports Center Outdoor Facilities Facility Policies Facility Use & Rental Requests Programs Group Fitness Classes Intramural Sports Chancellor’s Cup Massage Therapy Meet our Therapists Massage Therapy Appointment Request Personal Training Meet our Personal Trainers Personal Training Appointment Request Sport Clubs Strength & Conditioning Outdoor Adventure Center Bike and Ski Shop Climbing Wall Rentals Trips and Clinics Golf Simulator Special Events Shamrock Shuffle 2017 Past Events Contact Us Programs Group Exercise Intramural Sports Chancellor’s Cup Massage Therapy Meet our Therapists Appointment Request Outdoor Adventure Center Personal Training Meet our Personal Trainers Appointment Request Sport Clubs Strength & Conditioning Golf Simulator Hours and Location Information Announcements Sport Club Injury Report Form Sport Clubs Injury Report All accidents are to be reported immediately. Please fill in ALL information pertaining to the incident. Date of Injury* Time of Injury* : HH MM AM PM Name of party injured* First Last Sex of Injured*FemaleMaleLocal Address of Injured* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number of Injured*UW Oshkosh Affiliation of Injured*StudentFaculty/StaffGuestIf Student, Titan ID Number of InjuredPlease describe the nature of the suspected injury*Ex. bleeding to the upper arm Location*Please specify the exact location (i.e. Room Number, Activity Area, Field/Court Number) of the accident and the conditions in which the accident occurred.How did the injury occur?*Describe fully the events, actions, and conditions which contributed to the injury.What action was taken?*Precisely explain exactly what action was taken.Care of injured transferred toname, position, title Police called*YesNoIf yes, what time did the police arrive?Ambulance called*YesNoIf yes, please give time called and arrived in "other"If yes, what time did the ambulance arrive?Sent to Health Services*YesNoSent to hospital/clinic*YesNoIf sent to hospital/clinic, which one?Refusal of treatment*YesNoRefusal of transport*YesNoWitness #1 name, address, phone*Witness #2 name, address, phoneWitness #3 name, address, phoneAny additional or follow-up remarks?