Injury or Incident Form - Inter Lions FC

Injury or Incident Form
Type of Event (tick one or more)

DeathAccidentInjuryBehaviourCode of ConductOff Field IncidentOn FieldAdverseOther
Player or Persons Name*

First NameLast Name
Guardian if under 18

First NameLast Name
Referee (if unknown just type in unknown

First NameLast Name
Team (select from drop down)*
Email Address (Under 18 Guardian/Over 18)*
example@example.com
Contact phone number (Under 18 Guardian/Official//Over 18)

Phone Number
Where did the event Occur
Date of Event*

DayMonthYear
Date
Event Severity

Significant - report to Supervisor ImmediatelySerious - report to Supervisor ImmediatelyAll other incidents – report to Supervisor within 24 hours
Who was affected or who is the complainant?
Briefly describe the event*
Official (s) - Witnesses*
What actions did you take?
Assistance

AmbulanceMedicalCrowd ControlPoliceBoardAssocation
Follow Up*

DayMonthYear
Date
Follow up notes
What factors contributed?
Attach photos, physio/health practitioner reports here only

Browse Files

Cancelof
Follow Up - Recommended Action (Immediate or within 24-48 hours). Players are not to return to training/games until clearance has been emailed to admin@interlions.com.au

ObservationMonitorConciliationNo Action
If you require insurance go to the club website and follow FNSW guidelines or go to FNSW website directly

YesNo
Person Filling out this Form*
Should be Empty: