Injury Report The Injured Person Question Title * 1. Date of Injury Date / Time Date Time AM/PM - AM PM Question Title * 2. Location of Injury CSLL Major Field CSLL Minor Field CSLL Farm Field Mountain School Field Main Street Elementary Fields Soquel Elementary Field Santa Cruz Gardens Elementary Brommer Street Park Field New Brighton Middle School Field Other (please specify) Question Title * 3. Injured Person's Name Question Title * 4. Injured Persons Age 4 5 6 7 8 9 10 11 12 Other (please specify) Question Title * 5. Was the Injured person a player, manager, coach or league volunteer? Yes No Don't know Question Title * 6. Injured person's address Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Country Email Address Phone Number Question Title * 7. Is the injured person a minor? Yes No Don't know Question Title * 8. Parent's Contact Information Name Company Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number 25% of survey complete. Next
