HACKNEY RFC ACCIDENT REPORT FORM
This form is to record details of players treated by club first aiders. Please complete in all cases of suspected concussion and any other non trivial injury when a player is removed from the pitch particularly those that require a visit to A&E. Thank you
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What Group Does The Individual Play With *
Name of Age Grade Individual  *
Date of Birth *
MM
/
DD
/
YYYY
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Where Did The Incident Take Place?
 *
Pitch Type *
What Was The Activity *
What Is The Injured Area *
Is There A Chance Of Concussion? *
Describe The Injury *
What Is The Cause of The Injury? *
Describe In Detail What Happened? *
Was First Aid Administered? *
If You Answered Yes To The Above, Who Provided The First Aid and What First Aid Was Given?
Was There A Witness? *
If You Answered Yes To The Above, Who Witnessed The Incident?

Please Provide Name & Contact Information.
Was Medical Assistance Called? *
If You Answered Yes To The Above, What Medical Assistance Was Called?
Was A Responsible Adult or Guardian Informed? *
If You Answered Yes To The Above, Who Was Contacted and When?

Please Provide Name & Contact Information.
Any Of Information You Think Is Relevant *
Submit
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