SPORTS INJURY REPORT FORM
INSURED PERSON DETAILS
NAME:
DATE OF BIRTH:
/
Day
/
Month
Year
Date
GENDER:
ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE:
KNOWN ALLERGIES/MEDICAL CONDITIONS/MEDICATIONS:
PARENT/GUARDIAN:
ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE:
INCIDENT DETAILS
DATE:
/
Day
/
Month
Year
Date
TIME:
VENUE:
EVENT: (ie high jump, hurdles etc)
INCIDENT: (please provide a brief outline of what occurred)
IS ANYONE RESPONSIBLE FOR THE INJURY? (If yes, please provide details)
INITIAL ASSESSMENT (tick which is applicable)
RESPONSIVE:
Yes
No
CLEAR AIRWAY:
Yes
No
BREATHING:
Yes
No
PULSE:
Yes
No
BLEEDING:
Yes
No
INJURY TO: (part of the body)
REMOVAL FROM SITE: (walk, carry, ambulance)
FIRST AID TREATMENT PROVIDED
Outline:
FINAL ASSESSMENT: Did the athlete return to competition?
Yes
No
ACTION TAKEN: (if required & include if it was preventable)
FIRST AID PERSON: (Name)
WITNESS: (Name)
WITNESS: (Phone)
NAME OF CLUB SIGNATORY:
SIGNATURE:
DATE
/
Day
/
Month
Year
Date
CLAIM FORM: Was a personal accident claim form provided?
Yes
No
Preview PDF
Submit
Should be Empty: