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General Information Membership Policies and Procedures

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Fitness and Wellness

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Competitive Sports

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Aquatics

NSU Aquatics Center
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Canvas SharkLink Abraham S. Fischler College of Education and School of Criminal Justice Barry and Judy Silverman College of Pharmacy College of Computing, AI, and Cybersecurity College of Dental Medicine College of Optometry College of Psychology Dr. Kiran C. Patel College of Allopathic Medicine Dr. Kiran C. Patel College of Osteopathic Medicine Graduate Admissions H. Wayne Huizenga College of Business and Entrepreneurship Halmos College of Arts and Sciences Ron and Kathy Assaf College of Nursing Shepard Broad College of Law Undergraduate Admissions University School

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Incident/Injury Report

Incident/Injury - Report

Note: All fields with an * are required.

Section 1: Participant Information

Name: *

NSU ID#: *

You are: *

Other Role besides student, faculty or staff?

Gender: *

Local Address (street address): *

City: *

State:

Zipcode: *

Participant's Email: *

Phone Number: *

Alternate Phone Number: *

Emergency Contact (name and phone):

Would you like to receive a follow-up phone call? *

Section 2: Report Information

Choose your report type: *

Incident Information

Date:

Time:

AM or PM:

Detailed description of Incident:

Action Taken:

Staff on Duty:

First Name:

Last Name:

Witness (if applicable):

Injury Information

Head

Face

Hand/Finger (R or L)

Leg (R or L)

Arm (R or L)

Knee (R or L)

Elbow (R or L)

Ankle (R or L)

Foot (R or L)

Neck

Shoulder (R or L)

Back

Other

Did victim refuse medical attention by staff?

Staff on Duty:

First Name:

Last Name:

Did Campus Recreation provide care?

Was EMS called?

If yes, time called:

Describe in detail the Care Given:

Was the victim transported to an emergency facility?

If yes, where?

If no, did victim:

If victim left site, did victim leave alone?

If No, With Whom?

Report Prepared by:

First Name: *

Last Name: *

Position:

Please verify that you have completed all required fields and are not a robot before submitting this form.

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