ACTIVITIES AND RECREATION

INCIDENT REPORT

www.campusrec.illinois.edu

PLEASE PRINT CLEARLY

All accidents are to be reported immediately. Forward this Accident Report to Ed Morford, Assistant Director of Risk Management.

Name of Injured: Anders Brown

Age of Injured: 8
Local Address:

1600 Mullikin Drive Champaign, IL 61820

Phone:

(217) 753-4869

E-mail:

AandABrown@gmail.com

Time and Date of Injury: 3/12/16 @ 7:40 p.m.

Was emergency dispatch (911) called?

Yes

No

Exact location where accident occurred

Activities and Recreation (ARC) main hallway, water fountains in front of Gym 3

Describe the accident as accurately as possible:

What activity was the injured engaged in?

Two young boys were planning imaginary baseball when the injured (Anders) slid into a base while running and hit the side of
his head on the drinking fountain.

Describe how the injury occurred

The two young boys were pretending to play baseball. The injured (Anders) was sliding into the base and hit the side of his
head on the drinking fountain.

Describe the nature of the injury

Side of head hit on drinking fountain pretty hard; slight bump no blood, cut, or serious pain. The child began to cry,
but was able to stand up, walk, and talk after he was calmed down.

What steps did you take to address the injury?

As a part-time employee, I assisted the boy into a seated position, asked what had happened, had my supervisor (Robin)
find the child (Anders) parents in gym 3. After being settled down, Robin and I asked both the parents and child if any
extra assistance (paramedics/first aid) was necessary. We decided to give the child an ice pack and filed injury report.

Continue to describe the accident:

What options did you make available to the injured party?

We offered to call paramedics, visit the on-staff trainer, perform first aid on the spot. All were declined, the parents
and child settled on an ice pack to keep the bump from swelling.

Minors:

Read the following statement to the injured party when possible

You have the right to refuse medical treatment as recommended and decline the help of
Emergency Medical Personnel and an ambulance as recommended. In addition, you should know
that the University of Illinois is not financially responsible for any costs incurred by use of an
outside medical facility. Do you have any questions?

Please indicate below if the individual:

Declined

or

Accepted

recommended treatment

Declined

or

Accepted

transport

Declined

or

Accepted

EMS assistance

Signature of Club Sport Officer

Name of Club Sport Officer completing the form (PRINT):

Signature of Club Sport Officer completing the form:

Allie Busse

Allison Busse