East Coast Umpires Association

196 Daylily Blvd
Nokomis, FL 34275
631-561-3978

Injury Report

This report needs to be completed within 24 hours. Lack of timely information may effect your insurance coverage.

Reporting Umpire Full Name

Date of Event

MM/DD/YYYY

Arbiter Game Number

Name of League

Field Location

Name of Person Injured

Who was injured?

Were the police notified?

Police

Yes No

Who responded?

Select/Deselect All

Suffolk County Police Nassau County Police Suffolk County Sheriff Riverhead Police Southold Police East Hampton Police NYS Trooper Other Nobody

Choose all that apply

Police Report Number

Was the injured party removed from the field by ambulance?

Ambulance

Yes No

Name of Ambulance Co.

Describe Injury

If an umpire was injured, do you believe they/you suffered a concussion?

Umpire Injury?

Yes No

Your Email

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