Activities/Reporting A Safety Awareness Program's
Incident/Injury Tracking Report

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: (      ) _______________

Parent's Address (If Player): _________________________________ City: ___________________________

Incident occurred while participating in:
A.) ___ Baseball ___ Softball ___ Challenger ___ TAD  
B.) ___ Challenger ___ T-Ball (5-8) ___ Minor (7-12) ___ Major (9-12) ___ Junior (13-14)
  ___ Senior (14-16) ___ Big League (16-18)      
C.) ___ Tryout ___ Practice ___ Game ___ Tournament ___ Special Event
  ___ Travel to ___ 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: ____________________
(I yes, the player must present a non-restrictive medical release prior 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 __ Thrown or __ Batted
__ collision with: __ Player or __ Structure
__ Grounds Defect
__ Other: _________________________________
 B.) Adjacent to Playing Field
___ Seating Area
___ Parking Area
C.) Concession Area
___ Volunteer Worker
___ Customer/Bystander 		D.) Off Ball Field
___ Travel:
___ Car or ___ Bike or
___ Walking
___ League Activity
___ Other: ______

Please give a short description of incident:_________________________________________________
________________________________________________________________________________________

Could this accident have been avoided? How:______________________________________________

This form is for Little League purpose only, to report safety hazards, unsafe practices and/or to contribute positive ideas in order to improve league safety. When an accident occurs, obtain as much information as prossible. For all claims or injuries which could become claims, please fill out and turn in the official Little League Baseball Accident Notification Form available from your league president and send to Little League Headquarters in Williamsport (Attention: Dan Kirby, Risk Management Department). Also, provide your District Safety Officer with a copy for District files. All personal injuries should be reported to Williamsport as soon as possible.

Prepared By/Position: ___________________________ Phone Number: (      ) _______________________
Signature: ____________________________________ Date: ______________________________________