Accident Reporting Form

Name and Location of facility *

Your answer

Full name of the coach supervising the session *

Your answer

Full name of the injured person *

Your answer

Full address of the injured person *

Your answer

Age of the injured person *

Your answer

Date of accident *

YYYY

Time of accident *

Time

Nature of injury, including location on body *

Your answer

Nature of any injures/after-effects which developed later *

Your answer

FULL details of the accident including; how it happened, what activity was being performed, where it happened (if off pitch) *

Your answer

Witness name(s) and address(es) *

Your answer

Action taken *

Your answer

Police called? *

Yes

Ambulance called? *

Yes

Facility manager informed? *

Yes

Facility accident book completed? *

Yes

Parent informed? *

Yes

Details of first aid given *

Your answer

Other actions? *

Your answer

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