Injury / Accident Report
Gymnastics NSW
Office Use Only - Report File Number
Name of person completing form
First Name
Last Name
Role of person completing form
e.g. physio, coach, event manager
Date when injury occurred
/
Day
/
Month
Year
Date
Location where injury occurred:
Venue name and location within venue
Date when injury is evident
/
Day
/
Month
Year
Date
Personal Details of Injured Person
Name of Injured Person
First Name
Last Name
Gymsport injured person was primarily involved with at time of injury:
Please Select
Acrobatics
Aerobics
FreeG
GfA
Men's Artistic
Rhythmic
TeamGym
Trampoline
Women's Artistic
Date of Birth
/
Day
/
Month
Year
Phone Number
Please enter a valid phone number.
Format: 0000 000 000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State
Post Code
Injured person
Athlete
Coach
Other
Gender
Male
Female
Non-binary
Other
Accident Details
First Aid Provided by
First Name
Last Name
Signature of person providing First Aid
Has an ambulance been recommended?
Yes
No
N/A
Initial treatment provided:
No treatment required
CPR
Crutches
Dressing
Massage
RICER
Sling/Splint
Strapping
Stretching
Other
Did the accident occur during
Training
Competition
Warm-up
Other
Symptoms of the injury
Blisters
Bleeding
Bleeding nose
Bruising / contusion
Burn
Cardiac problem
Choking
Concussion / head injury
Cramp
Cut
Dislocation
Electrical shock
Graze / abrasion
Inflammation
Insect bite / sting
Loss of consciousness
Poisoning
Respiratory problem
Spinal injury
Sprain
Strain
Suspected bone fracture / break
Other
Full description of injuries:
Body part(s) injured:
How did the injury occur?
Collision with fixed object
Collision / contact with another person
Fall from height / awkward landing
Fall / stumble at same level
Overbalance
Overstretch
Slip/Trip
Other
Describe in FULL DETAIL what occurred:
Use full names of any persons involved and age of any child/young person. Include any extra detail regarding how the injury occurred.
Follow-up action required:
None
Ambulance
Medical Practitioner / Physio
Hospital
Other
Any additional information on follow-up treatment required
Details provided to injured person; e.g. referred to see personal physiotherapist
Subsequent treatment (if known):
Signature of person completing form
Date
/
Day
/
Month
Year
Date
Name of Supervisor / Manager
First Name
Last Name
Signature of Supervisor / Manager
Date
/
Day
/
Month
Year
Date
Name of Parent / Guardian
First Name
Last Name
Phone Number of Parent / Guardian
Please enter a valid phone number.
Format: 0000 000 000.
Email of Parent / Guardian
example@example.com; A copy of this form will be sent to the email provided
Signature of Parent / Guardian
Date
/
Day
/
Month
Year
Date
Supervising Coach
First Name
Last Name
Statement by Supervising Coach
Describe what happened. Use the full name of all people involved.
Supervising Coach Signature
Witness statements completed:
Yes
No
N/A
Additional notes:
Attach any other relevant documents and/or photos:
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