Name of injured person_______________________ Age: ____ Sex: __ Male __ Female
League Name_______________________ League ID: __ - _ - __
Incident Date: ____________Incident Time: _________
Injured Person's Name: ____________________ Date of Birth: _________
Address:__________________________City: _____________________
State ____Zip:_________ Home Phone: ______________
Parent's Name (If Player):________________ Work Phone: _____________
Parents' Address (If Different):_______________________________________
City:__________________________State:_______________ Zip:__________

Incident occurred while participating in:
__ T-Ball (5-8) __ Minor (7-12) __ Major (9-12) __ Softball
__ Practice __ Game ___ Tournament
__ Travel to or from ______________________________________________

Position/Role of person(s) involved in incident:
__ Batter __Pitcher __ Catcher __First __Second __Third __Shortstop __Left Field
__Center Field __Right Field __Umpire __Coach __Spectator __Other ___________
Was first aid required? __ Yes __ No
If yes, what, ____________________________________________________________
Was professional medical treatment required? __ Yes __ No
If yes, what _____________________________________________________________
(If yes, the player must present a non-restrictive medical release prior to to being allowed in a game or practice.)

Type of incident and location: __ Sliding __ Thrown or __ Batted Ball __ Base Path
__clubhouse __Dugout

On Primary Playing Field:
__ Collision with: __Player or __Structure __ Grounds Defect __ Other: _____________
Adjacent to Playing Field __Seating Area __ Parking Area __Concession Area
__Volunteer Worker __Customer/Bystander
Off Ball Field: __Travel: __Car __Bike __Walking
__ League Activity __Other: _______________________________________________
Please give a short description of incident: _____________________________________
______________________________________________________________________
______________________________________________________________________
Could this accident have been avoided? How: __________________________________
________________________________________________________________________
Prepared By: _____________________Position: ______________Phone_____________
Signature: _______________________Date: _____________

This form is for Little League purposes only, to report safety hazards, unsafe practices and/or to contribute positive ideas in order to improve league safety. When an accident occurs, obtain as much information as possible. For all claims or injuries which could become claims, please fill out and turn in the official Little League Baseball
Accident Notification Form available from your league president and send to Little League Headquarters in Williamsport (Attention: Dan Kirby, Risk Management Department). Also, provide your District Safety Officer with a copy for District files. All personal injuries should be reported to Williamsport as soon as possible.