Injury or Incident Form - Inter Lions FC

Injury or Incident Form

Read this form carefully and ensure your input is accurate
Type of Event (tick one or more)

DeathAccidentInjuryBehaviourCode of ConductOff Field IncidentOn FieldAdverseOtherPotential safety hazzards
Player or Persons Name*

First NameLast Name
Guardian if under 18

First NameLast Name
Female or Male Competition

FemaleMale
Team (select from drop down)*
If you have selected association team type in the age group
Email Address (Over 18+ Player email address Under 18 Guardians email address)*
example@example.com
Contact phone number (Under 18 Guardian/Official//Over 18)

Country Code (61) Australia onlyMobile number
What location did the event occur
Did this happen during

TrainingMatchOff Field
Date of Event*

DayMonthYear
Date
Event Severity

Significant - report to Supervisor ImmediatelySerious - report to Supervisor ImmediatelyAll other incidents – report to Supervisor within 24 hours
Describe the event in point form *
Official (s) - Witnesses*
What action took place
Are you a:

GuardianPlayerOfficial of the club
Assistance Required

Ambulance/HospitalMedicalCrowd ControlPoliceBoardAssocationClub PhysioExternal PhysioDoctor
Follow Up*

DayMonthYear
Date
Follow up notes
What factors contributed?
Select the role you undertake at the club

PlayerTeam ManagerCoachGuardianOfficial
Attach photos, physio/health practitioner reports here only

Browse Files

Cancelof
If you require insurance or clubs declaration select yes or no and go to FNSW website directly and download the form if it is required

YesNo
Follow Up - Recommended Action (Immediate or within 24-48 hours). Players who are injured are not to return to training/games until return to football activities are undertaken.

ObservationMonitorConciliationNo ActionSuspended from all football activities until Football Australia form is filled and submitted to club
Person who filled out this Form*
Should be Empty: