Name and Location of facility *

Full name of the coach supervising the session *

Full name of the injured person *

Full address of the injured person *

Age of the injured person *

Date of accident *

Time of accident *

Nature of injury, including location on body *

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

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

Witness name(s) and address(es) *

Action taken *

Police called? *

Ambulance called? *

Facility manager informed? *

Facility accident book completed? *

Parent informed? *

Details of first aid given *

Other actions? *