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 *
MM
/
DD
/
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? *
Ambulance called? *
Facility manager informed? *
Facility accident book completed? *
Parent informed? *
Details of first aid given *
Your answer
Other actions? *
Your answer
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