Injury Report Form - Online PIlot - Jr. Teams

THIS FORM IS ONLY TO BE USED BY JUNIOR A TEAMS IN ALBERTA. ANY OTHER SUBMISSIONS WILL NOT BE ACCEPTED, AND MAY RISK NOT BEING PROCESSED BY THE REQUIRED DEADLINE.

Hockey Alberta is undertaking a pilot project with Junior A teams in Alberta to develop a more efficient manner to process and follow up on Hockey Canada Injury Report forms. The goal of Hockey Alberta is establish a process where it is easier to track the progress of the claim.

The pilot project will see an additional step in the form submission process in the aftermath of an injury. The pilot process will include:

  1. The Hockey Canada Injury Report Form must be downloaded and filled out completely.
  2. This online version of the Injury Report Form must also be filled out.
  3. As part of submitting this online form, you are required to upload a PDF of the official Injury Report form.

If there are questions, or if issues arise with this form, contact Allison Marriott, Coordinator, Member Services.


NOTES:

  1. Claims must be presented within 90 days of the injury date.
  2. Forms must be filled out in full or form will be returned.
  3. This form must be completed for each case where an injury is sustained by a player, spectator, or any other person at a sanctioned hockey activity.
  4. If you are unable to complete the form in one sitting, click the SAVE FOR LATER button at the bottom of the form. Copy and save the link and password to allow you to access your form at a later date.
  5. Clicking SUBMIT sends the form directly to Hockey Alberta. If you, or another individual, would like a copy of the form contents, enter the email address(es) at the bottom of the form.

Hockey Canada Injury Report

Forms must be filled out in full or form will be returned. This form must be completed for each case where an injury is sustained by a player, spectator or any other person at a sanctioned hockey activity.

Required Fields *


Injured Participant

() - -


Division/ Category

Check at least one of the following:












Body Part Injured



Nature of Condition

Check at least one of the following:










On Site Care



Injury Conditions

Check at least one of the following:








Check all that apply:









Team Information



Health Insurance Information



Physician’s Statement



Dentist Statement

() - -


Hockey Canada Injury Report



Forward Submission

If you wish to forward this form submission to other related person(s) please enter their email addresses below, separated by commas. (ex: info@example.com,person2@example.com)