Exit this survey USPA Safety Injury Report Question Title * 1. Injury: Head Injury/Concussion Broken Arm Broken Leg Broken Collarbone Broken Bone - other Eye Injury Neck Injury Back Injury Other (please specify) Question Title * 2. Male or Female Male Female Question Title * 3. Age *at time of injury 18 & Under 19-25 26-35 36-45 46-55 56+ Question Title * 4. Handicap *at time of injury B B.5 A A.5 1 1.5 2 3 4 5 6 7 8 9 10 Question Title * 5. What is your USPA Affiliation? *at time of injury Player Member (US Citizen) Affiliate Member (Non-US Citizen) Junior Member (JM) Collegiate Member (CM) Associate Member (AM) Other (please specify) Question Title * 6. Number of years playing polo: *at time of injury 0-5 5-10 10-20 20-30 30-40 40+ Question Title * 7. How many hours do you play per year? Question Title * 8. How many total injuries have you sustained while playing polo? Question Title * 9. When did the injury occur? Riding/Exercising Stick and Balling Practice USPA Tournament Game Club/League Game Other (please specify) Question Title * 10. Where did the injury occur? On the Track/Riding area Grass Field Arena Other (please specify) Question Title * 11. What level of polo where you playing in at the time of the injury? Junior Polo Interscholastic/Intercollegiate 0-4 Goal 6-8 Goal 10-14 Goal 16-20 Goal 22+Goal Other Other (please specify) Question Title * 12. Are you a professional polo player? *at the time of injury Yes No Other (please specify) Question Title * 13. Was the injury a result of: Falling off your horse Your horse falling Contact with another player Hit by a polo ball Hit by a mallet Other (please specify) Question Title * 14. Was your injury a result of: Your horse spooking/misbehaving/etc Dangerous riding Field/Arena conditions Other (please specify) Question Title * 15. Was your injury a result of a rules infraction? Yes No If Yes, please explain Question Title * 16. Was there an associated injury to the horse? Yes No If Yes - Please explain Question Title * 17. Did your injury require: (Check all that apply) Professional Medical Attention Hospital admission If admitted to a hospital, how many days were you admitted? Question Title * 18. How long before you were back to riding? Playing? Riding: Playing: Question Title * 19. Was emergency medial personnel at the game/field/arena when you were injured? Yes No Other (please specify) Question Title * 20. Were you wearing a helmet? Yes No Question Title * 21. What brand of helmet do you wear? Question Title * 22. Is your helmet NOCSAE certified? Yes No If No - Why Not? Question Title * 23. Were you wearing eye protection? Yes - Goggles Yes - Helmet mounted eyeproection (Facemask) Yes - Goggles and Helmet mounted eyeprotection No Question Title * 24. Please describe your injury. Done