Incident and Hazard Reporting
We thank you for taking the time to report a hazard or incident.
Your Name
*
First Name
Last Name
Email
*
Email of person completing the form.
Phone Number
*
Phone number of person completing the form.
Relevant Sport / Facility Activity
*
Rugby
Cricket
Netball
Gym
Squash
Other
Reporting a:
*
Hazard
Incident
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Next
Hazard
Please detail the hazard.
*
Upload a photo
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We encourage you to upload a photo of the incident.
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of
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Next
Incident
Name of person involved
*
First Name
Last Name
Date incident occurred
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Their age (best estimate if not known)
Their relationship to the club
*
Member
Parent of member
Supporter
Staff
Opposition player, parent, supporter
Other
Description of Incident
*
Location of incident
*
Please let us know which ground this incident occurred at.
Did it result in injury?
*
Yes
No
Type of injury
*
Concussion
Fracture
Dislocation
Serious Joint
Chest/Trunk
Other
Site of Injury
*
Head
Neck
Shoulder
Back
Arm
Thigh/Hamstring
Knee
Lower Leg
Other
Event Causing Injury
*
Tackle
Post Tackle (pre-ruck)
Scrum Engagement
Scrum Collapse
Lineout
Ruck
Maul
Collapsed Maul
Kicking
Running
Other
Treatment Provided on field / in venue by
*
Doctor
St Johns
Team Official
Referee Only
Other
Method of leaving the field / venue
*
Ambulance
Stretcher
Carried off
Walked off
Other
Submit
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