PMHA Injury Notification Form (Pelham Minor Hockey Association)

Print PMHA Injury Notification Form

Teams are to complete this submission to PMHA should any injury occur (serious or not) at a PMHA game, practice or event. This is NOT the official Hockey Canada Injury Report that must to be completed, this is an internal notification of injury only.

Injury Information

Please provide the information to the PMHA regarding what injury happened, where, when and to whom in this brief submission section.

Geographical Location of Injury^*

what city or arena did the injury incident take place in?

Date & Time of Injury^*

Open the calendar popup.

Open the time view popup.

please list the date and time that the injury took place

Name of Person Injured^*
PMHA Team^*
What was the injury?^*
Position of Person Injured^*
What immediate action was taken if any?

Please provide if this information is known at the time of completing this form. This would specifically refer to what happened at the rink. Example answers: player sent to hospital, player went home with parent, player will seek medical followup, player was bandaged and continued to play, coach that was injured has to leave the ice and rest in the dressing room
Team Event in which injury occured^*
GamePracticeTournamentOther
Did the person return to the activity/play after the injury occured?^*
YesNoFor a short timeYes but after time passed
Hockey Canada Injury Report Completed?^*
YesNoIt will be soonProbably not necessary
was an injury reported completed?

Form Completed by

Please provide the name of the Team Designate who is completing and submitting this form.

Person completing this form^*
PMHA Team^*
Position on the team^*

please list the position on the team of who is completing this form
Email of Person completing this form^*

Example: yo[email protected]. Your submission will be sent to this address.