HSA 012 Injury Notification

Injury Notification

HSA 012
Completion of this form is to advise of an injury; it is not a personal accident insurance claim form.
Club Name
Name of Player Injured

First NameLast Name
Address of Player Injured

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
FA Number
Contact Email of Player Injured
example@example.com
Opposition Club Name
Competition
Date of Match

DayMonthYear
Date
Match Venue
Time of Injury (in 24 hr format)
Injury Type
Which Side of the Body was Injured?
How did the Injury Occur?
Was an Ambulance Called?
If Available - Incident/Ambulance Number
Witness Name(s)
Upload Photos or Witness Statements of Injury

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