Injury Definition

Referee Injury
ReportSystem/IRSInjury
ReportSystem/IRSThe definition of an injury in the IIHF Injury Reporting System is as follows
1. An injury is considered reportable if a player misses a practiceor a game because of an injury sustained during a practice or a game2. The player doesn't return to the play for the remainder of the game following an injury
3. All concussions
4. Any dental injury
5. Any laceration which requires medical attention
6. All fractures(only one injury/form)

Country:__________________________________________________
IIHF Championship: _____________________________________________________Mark the area on the ice surface where theinjury occured.
Note that Home and Visitor ends are marked to
identify offensive and defensive activity

12

3

4

5

6

Side / Body part:1. N/A

2. Left

3. Other__________________________
1. Age2. Height (cm)3. Weight (kg)fill out a separate form for each injury
3. Right

Power Play

19. Chest
20. Abdomen
21. Kidneys
22. Upper Back
23. Lower Back
24. Coccyx
25. Buttocks
26. Pelvis
27. Groin

28. Genitals
29. Hip
30. Thigh
31. Knee
32. Leg
33. Ankle
34. Foot
35. Toes
36. Other: ______________

Position:
Game Official position:

Dental:1. Dental
Mouthguard?
Custom made?

1. Yes
1. Yes

2. No
2. No

1. Acute

Circle the appropriate structure involved:
1. ACL
2. PCL3. MCL
4. LCL

5. Meniscus

Grade:

3. _____

1. _____

2. _____

6. PF*

1. Referee
Centre2. HeadWing Referee
3. Linesman
Defence
4. Goalie

TimeTime Lost:
Lost:
Theis Official
Theamountamount ofof time
time player
the Game
expected
to beoutunableof playto officiateis expected
to be

NatureNature ofof injury:
injury:2. Recurrent:a. this season
b. last season

Diagnosis:
Diagnosis:
ICD-code

2. _____

3. _____

5/4
5/3
4/3
Cause
Causeofofinjury:
injury:Goalie1. Yes
2. No

1.
of Check
1. Type
Collision
BodyCheck
2. a.
Stick
Contact
Checkfrom Behind
3. b.
Puck
Contact
4. c.
BoardCheckContact
to the Head
5. Stick
Ice Contact2.
Contact
6. Puck
SkateContact
Contact
3.
7. Unintended
Goal Contact
4.
Collision
8. Fighting
Other: ____________________
5.
6. Non-Contact
7. Skate
8. Other: ____________________
Wasa penalty
Replacement: Called on the Play?
2 min.treatment
1. No, finished Game 1.
without
1. Yes
2. 2+2min
2. No,
returned to Game
aftertreatment
2. No

3. 2+10 min

3. Yes, immediately 4. 5+20 min
5.return
Other:_________
4. Yes, after attempt toto GameEquipment:
DG:

PF= Patellofemoral, Kneecap
1. _____

1. Return same day
2. Less than 1 week
3. 1 to 3 weeks
4. More than 3 weeks_________________________________________ ________________________________________

Circle the appropriate structure involved:
1. AC*
2. SC*
3. Glenohumeral
Grade:

1. Contusion
2. Sprain (Ligament)
3. Strain (Muscle-Tendon)
4. Laceration
5. Dislocation/Subluxation
6. Fracture
7. Neurotrauma/Concussion
8. Other _______________________

4. Both

10. Shoulder
11. Scapula
12. Upper arm
13. Elbow
14. Forearm
15. Wrist
16. Hand17. Thumb
18. Fingers

Shoulder:Dx/assessment:
Dx/assessment:___________________________

1. Head2. Face
3. Neck
4. Throat
5. Jaw/Chin
6. Teeth/Mouth
7. Eye8. Ear
9. Clavicle

Knee:

8Practice
Warm up
off-ice
2. 2ndon-iceoff-ice
3. 1st3rd2.
4. 3rdon-ice4. 2ndOT3.
5. Ot
playing time:_______________
SituationEven Strength
5/5Penalty Killing 4/5
4/4
3/5
3/3
3/4

9Player
information:Game Official
information:
2. Physiotherapist

7Y ____________

Game / Period
1.
1. warm
1st up91
Source of Diagnosis
1. Medical Doctor

D ___________ M___________

Visitor

Zone of Injury B

1. No contact with boards
2. Contact with boards

1

Home

Zone of Injury A

Date of injury:

AC= Acromioclavicular Joint
SC= Sternoclavicular Joint

1. Full Face mask
a. shieldb. cage
2. Visor
3. None____________________________

Injury Definition

Referee Injury
ReportSystem/IRSInjury
ReportSystem/IRS

The definition of an injury in the IIHF Injury Reporting System is as follows
1. An injury is considered reportable if a player misses a practiceor a game because of an injury sustained during a practice or a game2. The player doesn't return to the play for the remainder of the game following an injury
3. All concussions
4. Any dental injury
5. Any laceration which requires medical attention
6. All fractures(only one injury/form)

Country:__________________________________________________
IIHF Championship: _____________________________________________________Mark the area on the ice surface where theinjury occured.
Note that Home and Visitor ends are marked to
identify offensive and defensive activity

12

3

4

5

6

Side / Body part:1. N/A

2. Left

3. Other__________________________
1. Age2. Height (cm)3. Weight (kg)fill out a separate form for each injury
3. Right

Power Play

19. Chest
20. Abdomen
21. Kidneys
22. Upper Back
23. Lower Back
24. Coccyx
25. Buttocks
26. Pelvis
27. Groin

28. Genitals
29. Hip
30. Thigh
31. Knee
32. Leg
33. Ankle
34. Foot
35. Toes
36. Other: ______________

Position:
Game Official position:

Dental:1. Dental
Mouthguard?
Custom made?

1. Yes
1. Yes

2. No
2. No

1. Acute

Circle the appropriate structure involved:
1. ACL
2. PCL3. MCL
4. LCL

5. Meniscus

Grade:

3. _____

1. _____

2. _____

6. PF*

1. Referee
Centre2. HeadWing Referee
3. Linesman
Defence
4. Goalie

TimeTime Lost:
Lost:
Theis Official
Theamountamount ofof time
time player
the Game
expected
to beoutunableof playto officiateis expected
to be

NatureNature ofof injury:
injury:2. Recurrent:a. this season
b. last season

Diagnosis:
Diagnosis:
ICD-code

2. _____

3. _____

5/4
5/3
4/3
Cause
Causeofofinjury:
injury:Goalie1. Yes
2. No

1.
of Check
1. Type
Collision
BodyCheck
2. a.
Stick
Contact
Checkfrom Behind
3. b.
Puck
Contact
4. c.
BoardCheckContact
to the Head
5. Stick
Ice Contact2.
Contact
6. Puck
SkateContact
Contact
3.
7. Unintended
Goal Contact
4.
Collision
8. Fighting
Other: ____________________
5.
6. Non-Contact
7. Skate
8. Other: ____________________
Wasa penalty
Replacement: Called on the Play?
2 min.treatment
1. No, finished Game 1.
without
1. Yes
2. 2+2min
2. No,
returned to Game
aftertreatment
2. No

3. 2+10 min

3. Yes, immediately 4. 5+20 min
5.return
Other:_________
4. Yes, after attempt toto GameEquipment:
DG:

PF= Patellofemoral, Kneecap
1. _____

1. Return same day
2. Less than 1 week
3. 1 to 3 weeks
4. More than 3 weeks_________________________________________ ________________________________________

Circle the appropriate structure involved:
1. AC*
2. SC*
3. Glenohumeral
Grade:

1. Contusion
2. Sprain (Ligament)
3. Strain (Muscle-Tendon)
4. Laceration
5. Dislocation/Subluxation
6. Fracture
7. Neurotrauma/Concussion
8. Other _______________________

4. Both

10. Shoulder
11. Scapula
12. Upper arm
13. Elbow
14. Forearm
15. Wrist
16. Hand17. Thumb
18. Fingers

Shoulder:Dx/assessment:
Dx/assessment:___________________________

1. Head2. Face
3. Neck
4. Throat
5. Jaw/Chin
6. Teeth/Mouth
7. Eye8. Ear
9. Clavicle

Knee:

8Practice
Warm up
off-ice
2. 2ndon-iceoff-ice
3. 1st3rd2.
4. 3rdon-ice4. 2ndOT3.
5. Ot
playing time:_______________
SituationEven Strength
5/5Penalty Killing 4/5
4/4
3/5
3/3
3/4

9Player
information:Game Official
information:
2. Physiotherapist

7Y ____________

Game / Period
1.
1. warm
1st up91
Source of Diagnosis
1. Medical Doctor

D ___________ M___________

Visitor

Zone of Injury B

1. No contact with boards
2. Contact with boards

1

Home

Zone of Injury A

Date of injury:

AC= Acromioclavicular Joint
SC= Sternoclavicular Joint

1. Full Face mask
a. shieldb. cage
2. Visor
3. None____________________________