Incident Report - The Sports Compliance Company

Date / Time of Incident

Date

Time

Summary of report. Describe in chronological order, including how and when you learned of the incident.

Information About the Injured Party

Injured Party's Name *

First

Last

Injured Party's Phone *

Injured Party's Age *

Injured Party's Gender *

Injured Party's Address

Address Line 1

Address Line 2

City

State

Zip Code

Inured Party's Emergency Contact Information

First

Last

Name, Contact Numbers, Emails if you have them on file

Email (1st Emergency Contact)

Inured Party's Emergency Contact Information (2nd contact, if known)

First

Last

Name, Contact Numbers, Emails if you have them on file

Email (2nd contact, if known)

What Is the injured party's team name? *

Injured Party's Youth Sports Company Name *

Injured Party's Youth Sports Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Where does this team normally practice?

Injured Party's Position on Team *

Injured Party's Coach Names and contact information: *

Provide names and contact inforrmation of each coach for the team.

Information About First Aid and Professional Medical Care

Was any first aid required: *

If yes, by whom? *

Please describe the first aid treatment provided: *

Was professional medical treatment required? *

(If yes, the player must present a non-restrictive medical release prior to being allowed in a game or practice.)

If professional medical attention required, please describe: *

Was family member or emergency contact called? *

You answered yes. Who did you call, and what is their contact number? *

List name and contact information for family member or emergency contact you called.

CPS / Law Enforcement Report Information

What is the name of the agency you reported this incident to? *

Who did you speak to? Please provide an operator or badge number if you have it. *

What is your report number? *

What is the address of the agency you reported this incident to? *

What is their phone number? *

Did you report to a 2nd agency or sport federation? *

Please enter 2nd agency or sport federation contact details below.

Did you report to a 3rd agency or sport federation?

Please enter 3rd agency or sport federation contact details below.

Documentation Uploads

File Upload - 2GB maximum per file. Files larger than 2GB need to be submitted through our upload link (Home page | Reports and Submissions | Documentation Upload)

Click or drag files to this area to upload. You can upload up to 10 files.

Upload any videos, photos, or link to security camera footage of the event if available.

Please provide link to large files:

CONTACT INFORMATION FOR REPORTING PARTY

Report prepared by *

First

Last

Employer or Affiliated Sport Organization

Phone *

Email (will receive copy of report) *

Work Address *

Address Line 1

Address Line 2

City

State

Zip Code

I wish to remain confidential *

Keep my name confidential, but I understand that if law enforcement is required the reporters name must be provided to them.
I am comfortable with my name on reports shared with the sport federation.

Signature *