ACCIDENT REPORTING FORM
To be completed for ANY Accident / Injury sustained on club premises. This does not necessarily need to be during a game.
Email address *
Name of Person Reporting Accident *
Your answer
Contact Number *
Your answer
Address *
Your answer
Your relationship to injured person (Tick all that apply) *
Required
Did you DIRECTLY witness the accident? *
PERSON AFFECTED
Please record full details
Name: *
Your answer
Home Address: *
Your answer
Postcode
Your answer
Age of Player *
Your answer
Details of Where Injury Occurred (e.g. On pitch behind clubhouse)
Address where injury occurred *
Your answer
Date: *
MM
/
DD
/
YYYY
Time: *
Time
:
Type of Event: *
Type of Pitch *
Nature and description of injury
Please record as much detail as possible, including the suspected cause of the incident
Nature of suspected injury *
Your answer
Description of incident *
Your answer
Was an ambulance called? *
Advice given by first aid personnel (IF KNOWN)
Your answer
Did the injured person attend hospital? *
Any other information you wish to record?
Your answer
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