ASAP Form

A Safety Awareness Program's Incident/Injury Tracking Report

North Natomas Little League (405-06-173329)
Incident Date*

MonthDayYearHourMinutesAM/PM Option
Field Name & Location*
Injured Person's Name*

First NameLast Name
Date of Birth

MonthDayYear
Age
Sex*

MaleFemale
Injured Person's Address (if known)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Injured Person's Home Phone

Area CodePhone Number
Parent's Name (if player was injured)*

First NameLast Name
Work Phone

Area CodePhone Number
Parent's Email*
example@example.com
Program*

BaseballSotfballChallengerTAD
Division*

T-BallRookieMinorMajorIntermediate 50/70JuniorSeniorBig LeagueChallenger
Activity*

PracticeGameAssessmentTournamentSpecial EventTravel toTravel fromOther
Position or role of person(s) involved in incident*

BatterBase RunnerPitcherCatcherFirst BaseSecond BaseThird BaseShortstopLeft FieldCenter FieldRight FieldUmpireCoach/ManagerSpectatorVolunteer
Type of injury (e.g., sprained ankle, bloody nose, heat exhaustion, etc.)*
Was first aid required?*

YesNo
If 'Yes' what first aid was administered?*
Was professional medical treatment sought?*

YesNo
***If Yes, please note the player must present a non-restrictive medical release prior to being allowed in a game or practice.
Where exactly on the primary playing field did the incident occur?*

Incident did not occur on primary playing fieldBase Path - RunningBase Path - SlidingHit By Ball - PitchedHit By Ball - ThrownHit By Ball - BattedCollision with PlayerCollision with StructureGrounds DefectOther
Where exactly did the incident occur if it was adjacent to the playing field?

Incident was not adjacent to playing fieldSeating AreaParking AreaOther
If the injury occurred in the concession area, who in the the concession area was involved in the incident?

Incident did not occur in the concession areaVolunteer WorkerCustomer/BystanderOther
If the incident did not happen on or near the ball field, where/how did it occur?*

Travel by CarTravel by BikeWalkingLeague ActivityN/AOther
Please give a short description of the incident*
Could this accident have been avoided?*

YesNo
If Yes, how?*
Prepared by*

First NameLast Name
Your Position (e.g., Manager, Team Parent, Umpire)*
Preparer's E-mail*
Preparer's Phone Number*

Area CodePhone Number
Phone Type

MobileHomeWork
This form is for North Natomas Little League use only and will not be sent to Little League International. The information you are submitting will be used to help NNLL evaluate potential 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 Accident claims or injuries that could become claims to any eligible participant under the league's Accident Insurance policy, please complete the Accident Notification Form available at http://www.littleleague.org/Assets/forms_pubs/asap/AccidentClaimForm.pdf and send to Little League International. For all other claims to non-eligible particpants under the Accident policy or claims that may result in litigation, please fill out the General Liability Claim form available here: http://www.littleleague.org/Assets/forms_pubs/asap/GLClaimForm.pdf.
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A Safety Awareness Program's Incident/Injury Tracking Report