Township Of Mahwah
Injury Report Form
Date of Injury:____________ Place of Injury:_________________________________________
Injured:___________________________________________________Age:________Sex:_____
Address:_________________________________________Phone:________________________
City:_______________________________________State:_______________Zip:____________
Association with Program:________________________________________________________
(e.g. athlete, coach, spectator)
Description of Circumstances:_____________________________________________________
Action Taken: (check all that apply)
____non required ____injured refused treatment
____Parent called at _____am/pm Caller:____________________________________________
First aide given by:______________________________________________________________
Describe:__________________________________________________________
Ambulance called at:_________am/pm Caller:________________________________________
Injured taken to:________________________________________________________________
Via:______________________________________________________________
Others notified:____________________________________________________at______am/pm
Caller:____________________________________________________________
Witness: (1)___________________________________________Phone #__________________
(2)___________________________________________Phone #__________________
Date of Report:_____________________Prepared by:__________________________________
Signature:_____________________________________________________________________
Retain (1) copy of this report and submit a copy to Dawn DaPuzzo, Recreation Director
Township of Mahwah 475 Corporate Drive Mahwah, NJ 07430