Serious Injury Report (2020)
Serious injury reports must be completed for the following injuries:

- Any head or neck injury that requires the player to be transported directly from the ground to an emergency department, hospital or after hours medical centre
- Any injury that results in the admission of a player into hospital after the game
- Any injury that is expected to prevent a player from playing for a period of 8 weeks or longer

Serious injury reports must be completed within 48 hours of the injury coming to the notice of the referee or team management
Injured person first name *
Your answer
Injured person last name *
Your answer
Player's club/school *
Your answer
Player's NZ Rugby number (if known)
Your answer
Date of birth
MM
/
DD
/
YYYY
Gender
Your answer
Playing Position * *
Player's Grade *
Your answer
Contact Details of Person Completing Form
First name *
Your answer
Last name *
Your answer
Club Email Address - this will be where your injury report will be sent to *
Your answer
Mobile *
Your answer
Home phone
Your answer
Designation - Referee, Team Manager *
Your answer
Club / School
Your answer
Provincial Union *
Give a short description of the law
Your answer
Location details
Date *
MM
/
DD
/
YYYY
Time
Time
:
Place
Your answer
The injury occurred during
Type of injury *
Required
Event causing injury *
Required
Injury site *
Required
Blue card *
Your answer
Treatment details
On-field treatment provider *
Required
Method of leaving field *
Required
Brief description of how the injury occurred *
Your answer
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