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HOCKEY CANADA INJURY REPORT

CLAIMS MUST BE PRESENTED WITHIN 90 DAYS OF INJURY. INJURY DATE:

/

/

_____ _____ _____

INJURED PARTICIPANT:

  • Player

  • Team Official

  • Game Official

  • Spectator

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: ________________________ ________________________

Parent/Guardian:

_______________________________________________________________________________________________

DIVISION:

Initiation

Novice

Bantam

Midget

  • Atom

  • Juvenile

  • PeeWee

CATEGORY:

  • A

  • D

AA

AA

A

DD

E

  • Senior

  • Adult Rec.

B House Other BB Major Junior Minor Junior __________________________________________ C CC

BODY PART INJURED: * visit the Hockey Canada web-site for an optional questionnaire *

Throat

Dental Upper

Chest

Skull

Lower

Abdomen

Head

Back

Trunk

Eye Area Face

Neck

Ribs

Shoulder

Hand/Finger

Hip

Upperarm

Forearm/Wrist

Groin

Elbow

Collarbone

Arm

  • Left Right

Pelvis

Leg

  • Thigh

  • Knee

  • Shin

  • Left

  • Right

  • Foot

  • Toe

  • Other

NATURE OF CONDITION:

  • Concussion Laceration

  • Contusion

  • Dislocation

  • Fracture

  • Separation

  • Sprain

  • Strain

  • Internal Organ Injury

ON-SITE CARE:

  • On-Site Care Only

  • Refused Care

  • Sent to Hospital, by:

  • Ambulance

  • Car

INJURY CONDITIONS:

Name of arena/ location:

___________________________________________________________

  • Exhibition/Regular Season

  • Playoffs/Tournament

  • Practice

  • Try-outs

________________________

  • Other

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:

LOCATION:

Hit by Puck

Collision with Boards

Non-Contact Injury

Hit by Stick Fall on Ice

Collision on Open Ice Checked From Behind

Collision with Opponent Collision with Net

  • Fight

  • Blindsiding

WEARING WHEN INJURED:

  • Other:

_____________________________________________________

ADDITONAL INFORMATION:

  • Defensive Zone Offensive Zon

e

  • Neutral Zone

  • Spectator Area

  • Bench

  • Behind the Net

  • Parking Lot

  • 3 ft. from boards

  • Dressing Room

  • Full Face Mask

  • Half Face Shield/Visor

  • Helmet/No Face Shield

  • Short Gloves

  • Intra-Oral Mouth Guard

  • Throat Protector

  • No Helmet/No Face Shield

  • Long Gloves

Has the player sustained this injury before?

  • Yes

  • No

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)

Date:

____________________________

TEAM INFORMATION: (To be completed by a Team Official)

Association: Team Official (Print): __________________________________________ Signature: ___________________________________________________ ______________________________________________________

Team Name : Team Official Position: Date: _______________________________________________________ ____________________________________________

_______________________________________________________________

HEALTH INSURANCE INFORMATION:

Occupation:

  • Employed Full-time

  • Employed Part-time

  • Unemployed

  • Full-Time Student

Branch APPROVAL

Employer (If minor, list parent s employer): ___________________________________________________________________________

1. Do you have provincial health coverage?

  • Yes No

Province:

___________________________________________

  • 2.

    Do you have other insurance?

  • 3.

    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:

  • Injured Person

  • Parent

  • Team

  • Other:

____________________________________

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