Fillable AYSO INCIDENT REPORT FORM (AYSO Volunteer Resources)

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AYSO INCIDENT REPORT FORM (AYSO Volunteer Resources)

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Country of origin: CANADA
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AYSO INCIDENT REPORT FORM
Complete this form for any of the following: (check type)
Injury/illness Threats Fights Property damage Calls to Police Other
Return completed form to the
Regional Commissioner,
Safety Director, Area Director,
or Tournament Director.
AFFECTED PARTY: Player Official Coach Spectator Volunteer Other
AYSO ID #
(Required)
Region #
(Required)
Last Name
First Name
MI
Birth date:
Phone:
Address:
City:
State:
Does the injured person have medical insurance?
YES NO
If yes, please provide name of company and policy #:
GUARDIAN/PARENT (if affected party is a minor):
Last Name
First Name
Address (if different than above):
Email 1: Cell Ph:
Email 2: Cell Ph:
Email 3: Cell Ph:
INCIDENT INFO:
Date of Incident:
Age Division:
Boys Girls Co-ed
Time of Incident:
Location (if applicable-Tournament name):
Team Involved #1: Coach Name: Region #
Team Involved #2: Coach Name: Region #
FOR INJURIES: BODY PART INJURED
TYPE OF INJURY/ILLNESS
FIELD SURFACE LOCATION
Ankle (L/R)
Knee (L/R)
Leg
Foot
Toe
Arm
Hand
Shoulder(L/R)
Wrist (L/R)
Finger
Eye (L/R)
Ear (L/R)
Nose
Head
Tooth
Back
Neck
Internal
No injury
Other
Abrasion
Burn
Cardiac
Cold Injury
Concussion
Contusion
Dislocation
Foreign Body
Fracture
Heat Exhaustion
Laceration
Nausea
Pain
Seizures
Sting/Bite
Strain
Sprain
Dirt
Grass
Turf
Indoor
Before Competition/Event
During Competition/Event
After Competition/Event
Concession Area
Parking Lot
Restrooms
CAUSE OUTCOME POLICE REPORT FILED:
Collision (participant/spectator)
Struck by falling/flying object
Struck by or fell into goal
Animal/insect bite/sting
Slip/Fall
Assault/Sexual
Assault/Non-Sexual
Property Damage
No care given:
Not Needed
Patient Refused
Releas
ed:
To Parent
To Personal Vehicle
Referral:
To Doctor
To Hospital/Clinic
EMS tra
nsport:
Region Recommended
Patient/Parent Requested
Yes No
Report No:
Officer’s Name & Contact No:
Describe how the incident, injury or property damage occurred:
(use the backside or attach a separate sheet if necessary – may attach a copy of the Referee Game Misconduct Report)
WITNESS INFORMATION – Confidential
Name
Address
Phone Number
Person/volunteer completing/submitting this form:
Name:
Signature:
Cell:
Position Title: E-mail address: Date:
RC or Safety Director (print name):
Signature:
Date:
AYSO Staff ONLY: Email completed form to riskmanagement@ayso.org or mail to AYSO, Attn: Risk Mgmt, 19750 S Vermont Ave, Suite
200, Torrance, CA 90502.
Rev 06-2020 hv
COVID-19
AM
Rev 06-2020 hv
AYSO Incident Report Form – Instructions
NOTE: This form should NOT be completed by a parent unless the parent is the coach.
Purpose:
The AYSO Incident Report Form is used whenever there is a personal injury or illness, damaged property, or threats and/or actual
physical violence surrounding an AYSO event (game, practice), property damage, or calls to the police. The form should be prepared by
the coach, AYSO Official, or AYSO Volunteer which may be a member of the regional staff such as the regional safety director, or by
tournament or event staff members.
Entry Instructions:
Form Preparation
The regional safety director should supply each coach with several copies of the form at the beginning of
each season. Additional copies should be available at each field site. Coaches who take teams to
tournaments should carry several copies of each form throughout the tournament season.
If there is an incident involving injury to a player or volunteer which will result in the filing of a SAI claim,
then an Incident Report Form should be completed as well.
If there are multiple affected parties to the same incident, then all parties should fill out their own form.
Note: The Region, Area or Tournament is responsible for mailing a copy of the Incident Report to
AYSO, Attn: Risk Management, 19750 S Vermont Ave, Suite 200, Torrance, CA 90502 or scan and email
a copy to riskmanagement@ayso.org.
Form Entries Fill out all entries on the form that pertain to the incident.
Witness Information
When an incident occurs, it is important to gather as much witness information as possible, especially if
the witness is independent or neutral. Use a separate page to collect each witness’s statement. In
addition to gathering the name, address and phone number of all witnesses, gather and attach as many
written statements as possible from the key witness. If the incident happened during a game, attach the
referee’s Game Misconduct Report as well.
Description of Incident
Provide as full a description as you can of the events surrounding the incident, attaching additional
pages if necessary (be sure that all additional pages are numbered and securely attached to the report.)
Routing
During an event or activity related to a region’s primary season, the completed form should be
submitted to the respective Regional Commissioner or Safety Director.
During a secondary activity (e.g. a tournament), the form should be submitted to the Regional
Commissioner, secondary activity’s director, or Regional Safety Director.
At a tournament, the tournament staff may prepare a report as well. In this case, a copy of the report
should immediately be sent to the respective Regional Commissioner(s).
In all cases, copies of the Incident Report should always be sent to the Regional Commissioner, Area
Director, Safety Director, and in the case of a secondary event the Secondary Event Director.
Note: A copy of the Incident Report must be sent to the AYSO, Attn: Risk Management,
19750 S Vermont Ave, Suite 200, Torrance, CA 90502 or email a copy to riskmanagement@ayso.org.
Retention
Incident forms should be maintained in a regional file and stored for a minimum of 15 years. In the case
of a secondary event which is sponsored at the area or section level, the secondary event host should
retain the original copy for a minimum of 15 years.
Secondary events must also send copies of the Incident Reports to AYSO, Attn: Risk Management to the
address or email listed above for storage.
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Completed 12 September 2021

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