HOCKEY CANADA INJURY REPORT
CLAIMS MUST BE PRESENTED WITHIN 90 DAYS OF INJURY. INJURY DATE:
_____ _____ _____
Forms must be filled out in full or form will be returned. This form must be completed for each case where an injury is sustained by a player,spectatororanyotherperson at a sanctioned hockey activity.
Birthdate: City/ Town Phone: (______) _______________________ / / Sex: (M) (F) Name: Address: Province: ____________________________________________________________ _____ _____ _____ __________________________________________________________ ________________________________ Postal Code: ________________________ ________________________
B House Other BB Major Junior Minor Junior __________________________________________ C CC
BODY PART INJURED: * visit the Hockey Canada web-site for an optional questionnaire *
Eye Area Face
NATURE OF CONDITION:
Internal Organ Injury
On-Site Care Only
Sent to Hospital, by:
Name of arena/ location:
Period #1 Gradual Onset Period #2: Other Sport Period #3 Other: Overtime # ________ ___________________________________ Yes No Warm-up Dry Land Training Was the injured player in the correct league and level for their age group? Was this a sanctioned Hockey Canada hockey activity? Yes No
CAUSE OF INJURY:
Hit by Puck
Collision with Boards
Hit by Stick Fall on Ice
Collision on Open Ice Checked From Behind
Collision with Opponent Collision with Net
WEARING WHEN INJURED:
Defensive Zone Offensive Zon
Behind the Net
3 ft. from boards
Full Face Mask
Half Face Shield/Visor
Helmet/No Face Shield
Intra-Oral Mouth Guard
No Helmet/No Face Shield
Has the player sustained this injury before?
If “Yes” how long ago ________________________________ Was a penalty called as result of the incident? Yes No Estimated Absence from hockey? 1 week 1-3 weeks 3+ weeks
DESCRIBE HOW ACCIDENT HAPPENED:
I hereby authorize any Health Care Facility, Phyician, Dentist or other person who has attended
(Attach page if necessary)
or examined me/my child, to furnish Hockey Canada any and all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment and copies of all dental, hospital, and medical records. A photostatic/electronic copy of this authorization shall be considered as effective and valid as the original.
Signed: ____________________________________________ (Parent/Guardian if under 18 years of age)
TEAM INFORMATION: (To be completed by a Team Official)
Association: Team Official (Print): __________________________________________ Signature: ___________________________________________________ ______________________________________________________
Team Name : Team Official Position: Date: _______________________________________________________ ____________________________________________
HEALTH INSURANCE INFORMATION:
Employer (If minor, list parent s employer): ___________________________________________________________________________
1. Do you have provincial health coverage?
Do you have other insurance?
Has a claim been submitted?
Yes No (If “Yes”, please submit claim to your primary health insurer.)
Yes No (If “Yes”, please forward primary insurer explanation of benefits)
Make Claim Payable To: