NNSWF Northern Inland - Injury Report

NNSWF Northern Inland - Injury Report

This form is to be used to report any injuries that occur to a participant, coach, team official, spectator, match official, or member of the public, either on the field or off the field. Even if you do not think the injury is serious, it is important to complete this form in as much detail as possible to assist future risk mitigation strategies, or to assist with the completion of a Personal Injury Claim.
Name of person making this report*

First NameLast Name
Contact number of person making this report (in case we need any further information)*
Email address of person making this report*
example@example.com
Details of Injured Person
Injured Person's Name*

First NameLast Name
Injured Person's Club*
Date of Birth (if known)

DayMonthYear
Date
Gender

MaleFemalePrefer not to answer this questionOther
Contact phone number, or their parent/guardian's number (if known)
Details of Injury
Date of Injury*

DayMonthYear
Date
Place injury occurred (eg name of ground, or street address)*
Time of Injury (if exact time not known please enter approximate time)*

Hour Minutes

AM/PM Option
Activity at time of injury (eg training, game, etc)*
Opposition Club name
Nature of Injury (include what the injury was and how it happened)*
Immediate treatment? (eg ice pack)*
(if no treatment given, write N/A)
Any further action taken (eg "did not move player and called ambulance")*
(if no further action take, write N/A)
Should be Empty:

Details of Injured Person