2008 Injury/Incident Tracking Report - West Windsor Little League (WWLL)
League Name: __West Windsor Little League (WWLL) _ League ID: __1701136 _ Incident Date: __________
Field Name/Location: _________________________________________________ Incident Time: __________
Injured Person’s Name: ____________________________________ Date of Birth: ______________
Address: ________________________________________________ Age: ________ Sex: c Male c Female
City: ____________________________State ________ ZIP: ________ Home Phone: ( ) ____________
Parent’s Name (If Player): ____________________________________ Work Phone: ( ) _____________
Parents’ Address (If Different): _________________________________ City ______________________________
Incident occurred while participating in:
A.) cBaseball cSoftball
B.) cT-Ball cRookie cAAA cMinor cMajor cJunior
C.) cTryout cPractice cGame cTournament cSpecial Event
cTravel to cTravel from cOther (Describe): ________________________________________
Position/Role of person(s) involved in incident:
D.) cBatter cBase Runner cPitcher cCatcher cFirst Base cSecond
cThird cShort Stop cLeft Field cCenter Field cRight Field cDugout
cUmpire cCoach/ManagercSpectator cVolunteer cOther: ___________________________
Type of injury: _____________________________________________________________________________
_________________________________________________________________________________________
Was first aid required? cYes cNo If yes, what: _________________________________
Was professional medical treatment required? cYes cNo If yes, what: _________________________________
(If 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 B.) Adjacent to Playing Field D.) Off Ball Field
cBase Path: cRunning cSliding cSeating Area cTravel:
cHit by Ball: cPitched or cThrown or cBatted cParking Area cCar orcBike or
cCollision with:cPlayer or cStructure C.) Concession Area cWalking
cGrounds Defect cVolunteer Worker cLeague Activity
cOther: ____________________________________ cCustomer/Bystander cOther: ________
Please give a short description of incident: _____________________________________________________
__________________________________________________________________________________________
Could this accident have been avoided? How: __________________________________________________
__________________________________________________________________________________________
This form is for Little League purposes 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 possible. For all claims or injuries that 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: _____________________________
