Old Dominion University Recreation and Wellness

Accident Reports & Refusal of Medical

I, the injuretl party, herein certify that the information set fo1th above is true and correct to the
best of my knowledge.

Injured Signature: ___ __ Date_/__/__

Signature ofParent/Lega! Guardian (if victim is a minor): ~ ~DateJ.l.f_CiJ-7
Signature of Staff Member filling out report:~~---_ __________ DatejJ_I_L:z/__.Q

Extra Info:
__1__Number of Patrons in the area at the t!me of accident.
-~ ___ Number of facility employees on duty at time of accident.
5 Number of additional staff supervising event (i.e. Intramural staff fitness staff etc.).
Describe condition of the area at the time of_the f'~cident:
--fl..L CVK4., Wt0 cieur ~--~ ..{)_o__ S ~t1> ~ (.A f c...-.e
:tct~C" o-~~;;Jit:J. ~~~V>-<--
1~ ~~-h~ mu----------------

Phone: _____ Address: _ _ _ __

Reviewed by: . _ _ _ _ Position: Date: I I

Cali Log

Attempt# l: Date: JL/~/1/J=l

Time: q{W\1 Caller Signature: ._u ~ctzf___
__ Left Message ../Left Message witil1)erson ___ Spoke with injured patronLNo Answer

Attempt# 2: Date: J2J ~ t7

/ Time: q
t<v!Cailcr Signatut~~l-#,..----
- - L~ft fvlessage ___-_~1-.. ~h f~,1~~~age \Vith Person _)(__Spoke \Vith ir;J~1~ed- patrun ____ N~-i t\ns\ver

AttempT# 3: Date: __r ______ _ Caller Signature:

~~ L,cft l\1essage __ L.eft fV1essage \v!th Person Spoke \V!th !n_Iured parron ~--1'\lo f\nS\Ver

Status of Injured J>crson ~#=

Date: l2J JJil) Tirne: _ _2;[_ ?V\/v) Caller Signatllre: .. . . _ . u-- __ _

_ ){_The injured person is fine. No complications.

l~he injury \vas serious enough to \V2!TFHlt Rdd1tionai rnediccd attention. -rhe injury ;..v~s
liiagnosed 3S ________________ ----~-----

------ --~~------

LJnkncnvn. (tinabie to contact the iruured per~on after J atten1pts.)

 Old DorrLinion University Recreation and Wellness
Accident Reports & Refusal of Medical

I
Date of Accident: V/1/{ 7
Time of Accident:___ { '- 00 ~

Personal Data 11 _
Name: __ ~-- ''1--(j~~------- ________ Gender: _ /V(_aA.e__
Local Adaress: __ ll~--.:>~+-~ _____ DateofBirth_1i~i:Qq
Locai PhoneJ](eO) --t-'3 ~- S7 ~ Status: Student Facultv/Staff Guest , /
If under 18, r;me and phone number of parent/legal guardian: l'4( ~ ~ _( ~
(I ~N] ct-L -5[[75
Details of Incident
Building/Area of incidenis
Fieid A Field B!C Po\vhatan Field ____ SRC
=--==Fitness Studio =-~=Pool -----z---Climbing Wall _____ OAP Trip
Location Within building/area (coun#,field#, mac/tine, etc):
Program Participating in: (check all that app(v)
Intramural Sports Infonnai Recreation _____ Aquatics
~-,--;_Ciub Sports Instructional Program Fitness
___ )(__Summer Camps Wcl!ness ____ OAP

P t of Body Injmed (check all that apply) _____ Right Left ______N/A
Head ---
Mouth ---
Wrist Torso Shin
Ear Neck Hand Groin Foot
__ Eye Shouider ___Finger __ Hip Toe
Face /\1"111 Back ___ Leg Other
Nose Elbow Chest Knee
Description oflww injury occurred: (attach additional information if necessary)
~- i~- 4o ~L~~-~~---bic----
~k-.~ 0~ _of-: +f-., h\.'-~t LAJ)~~-
_{A vv~ fv~ G0NL ~~t- 1--vs bud.
Immediate Action Taken
First Aid: (check aii that appM l'bme of Care giver: JCI.A/I..)--- ___ Position: W~W
__ >{__ Victim Selt'Care ____Stopped Bleeding __ __immobilized
Elevated _____ WashcJ WounJ _ X_j\ppiied lee
___ ------~ResGue Breathing CPR r'\ED
Backboard ____Other
(For Aquatics use onfy)(Type of Rescue) ___Assisted ____ Distressed __ Active Pass1vc
Describe in greater detail: (attach additional information if uecessmy)

--------------- ~~---------

Furt!,er Care: (check a!/ that app)

_3_ \Vent home on O\.vn ______ Returned to Activity ______ _Friend took home
____ Arnbulancc to f Jospitai __ -~Self/Friend to 1--Iosp!ta! _____ Se!f.'Fricnd to 1-iealth Center
Left Area l'~o Info

Refusal of Medical Assistance/Care

Ai: this time, I am refusing K.-@.4-initials)medicai assistanccican:- from the Old Dominion
lJniversity, Depnrtn1ent of Recreation and \\-'cHncss .

Date: I { : n t7