Hyperextension Injury Report Form
Use this form to record the details of a hyperextension injury, the symptoms observed, the immediate response, and any follow-up information needed.
Injury and Incident Details
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Location Where Incident Occurred
*
Activity Being Performed
*
Please Select
Walking
Running
Lifting
Carrying
Reaching
Pushing
Pulling
Sport/Exercise
Work Task
Other
Body Part(s) Affected
*
Neck
Shoulder
Elbow
Wrist
Thumb
Back
Knee
Ankle
Other
How the Hyperextension Occurred
*
Brief Description of the Incident
Symptoms and Immediate Response
Pain or discomfort severity
*
None
Mild
Moderate
Severe
Visible swelling or bruising
Swelling
Bruising
Both swelling and bruising
None visible
Range of motion limitation
*
No limitation
Mild limitation
Moderate limitation
Severe limitation
Was first aid provided?
*
Yes
No
Who provided first aid?
Has medical attention already been sought?
*
Yes
No
Reporting and Follow-Up Information
Injured Person Name
*
First Name
Middle Name
Last Name
Relationship to Incident (if applicable)
Reported to Supervisor/Coach/Manager?
*
Yes
No
Not yet
Witnesses (if available)
Recommended Follow-Up / Additional Notes
Submit Report
Should be Empty: