Scholar Victoria Injury Report Form
Coaches without medical training should refer all medical decisions to appropriately qualified persons. Do not attempt to 'diagnose' an injury. Users of this form are advised that information collected is confidential and subject to normal management of health records.
Date of injury (if filling out form later)
MM
/
DD
/
YYYY
Time of injury (if filling out form later)
Time
:
Name of injured person *
Your answer
Date of Birth
MM
/
DD
/
YYYY
Gender
Role of injured person
Name of first aid provider *
Your answer
Was an ambulance required? *
Nature of Injury *
Did the person return to activity immediately?
Suspected nature of injury (not a diagnosis)
Treatment
Brief description of injury (injury location, type of injury, treatment)
Your answer
How did the injury occur
Brief description of circumstance of injury *
Your answer
Name of person completing this form *
Your answer
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