Collegiate Sports Safety Form

Please fill in all fields and check all boxes that apply. Please feel free to provide additional information in the Comment boxes.

National Sports Safety Organization (NSSO)
8547 E. Arapahoe Road, Unit J-563
Greenwood Village, Colorado 80112
Email: info@nssousa.org

For General Information and
Questions, Please Call
Toll Free: 1-(888) 560-NSSO (6776)

Contact Information:

School Name:
Address:
City:
State:
Zip:
Phone:
Email Address:
Website:
Contact:
Contact Information Comments:


Please enter the following information if you are the individual who is preparing the Collegiate Sports Safety Report Survey.

Name:
Title:
Phone:
Email Address:
Survey Preparer Comments: 

Sports Safety Equipment

Please check the items you have on-site and indicate how many in the quantity box.

Airway Apparatus
Bulb Syringe:
Yes:
No:
Qty:
Adult Bag Valve Mask:
Yes:
No:
Qty:
Adult Nasal Cannulas:
Yes:
No:
Qty:
Adult non-re-Breather Masks:
Yes:
No:
Qty:
CPR Face Mask:
Yes:
No:
Qty:
Manual Suction Cup:
Yes:
No:
Qty:
Nasal Airway Kit:
Yes:
No:
Qty:
Oral Airway Kit:
Yes:
No:
Qty:
Defibrillator:
Yes:
No:
Qty:
Cervix / Vertebrae Apparatus
Adult Adjustable Cervical Collar:
Yes:
No:
Qty:
Bleeding Control
4" Kling:
Yes:
No:
Qty:
4x4 Gauze Pads:
Yes:
No:
Qty:
5x9 Gauze Pads:
Yes:
No:
Qty:
Band Aids:
Yes:
No:
Qty:
Injury Control
Penlight:
Yes:
No:
Qty:
Sterile Water:
Yes:
No:
Qty:
Bandage Shears:
Yes:
No:
Qty:
Instant Ice Packs:
Yes:
No:
Qty:
Latex Free Gloves:
Yes:
No:
Qty:
2" Tape Rolls:
Yes:
No:
Qty:
Stethoscope:
Yes:
No:
Qty:
Tongue Depressors:
Yes:
No:
Qty:
Trauma Shears:
Yes:
No:
Qty:
Triangular Bandages:
Yes:
No:
Qty:
Medical Record Devices
PDA (Personal Digital Assistant):
Yes:
No:
Qty:
Sports Safety Equipment Comments: 

Personnel On The Field Certified On CPR, AED And First Aid (Minimum 1)

Please check how many of the following personnel are present at practices and games.

Athletic Trainers:
Yes:
No:
Number At Practice:
Number At Games:
Paramedic/ EMTs:
Yes:
No:
Number At Practice:
Number At Games:
Physicians:
Yes:
No:
Number At Practice:
Number At Games:
Coaches/ Asst. Coaches:
Yes:
No:
Number At Practice:
Number At Games:
Student Assistants:
Yes:
No:
Number At Practice:
Number At Games:
Sports Safety Personnel Comments: 

Trained Personnel

Please check how many personnel have successfully completed First Aid, CPR and Automated External Defibrillator Training.

First Aid Training:
Number At Practice:
Number At Games:
CPR Training:
Number At Practice:
Number At Games:
AED Training:
Number At Practice:
Number At Games:
Sports Safety Training Comments: 

Health Screenings And Physical Exams

Do you require your athletes to complete a physical exam before participating in sports activities?

Yes:
No:
Health Screenings And Physical Exam Comments: 

Sports Safety Procedures

Do you have a sports safety manual or document that covers sports safety procedures to follow at all sports activities?

Yes:
No:
Sports Safety Procedures Comments: 

Thank you for completing the NSSO Collegiate Sports Safety Report. Please fax this document to NSSO at (888) 277-5582 or mail it to: National Sports Safety Organization, 8547 E. Arapahoe Rd., Unit J-563, Greenwood Village, CO 80112. We will contact you after we receive this document to verify the information before publication.

 

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BIG DISCOUNTS!

Your NSSO Membership Card entitles you to big discounts on a wide range of sports, health, safety and fitness products and services!

FREE FIRST AID KIT!

Every NSSO member receives this free first aid kit containing several sizes of band aids, bandages, gauze pads, plus first aid tape, antiseptic and ointment. This convenient size is great for travel, hiking, biking and more!

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