Accident Reporting Form
* Required
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
:
AM
PM
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
No
Ambulance called?
*
Yes
No
Facility manager informed?
*
Yes
No
Facility accident book completed?
*
Yes
No
Parent informed?
*
Yes
No
Details of first aid given
*
Your answer
Other actions?
*
Your answer
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