IGSA Accident/Injury Report

Accident/Injury Report Form
Name of person injured*

First NameLast Name
Date of birth*

DayMonthYear
Venue*
Playing area (as listed on draw e.g. "Central Field 1" or "Metro Indoor Court 3")*
Name of IGSA venue convener*
School attended by/associated with injured person*
Sport/activity*
If other, please list the sport/activity*
Team of injured person (e.g. ABB01)*
Division of injured person (e.g. S08, J12, Y705)*
Date/time of injury*

DayMonthYear
Date
Hour MinutesAM/PM Option
Description/signs of injury (please select all that apply)*

BlistersBleeding noseBruising / contusionCutGraze / abrasionSprain (ligament/tendon)Strain (muscle)Inflammation / swellingCrampSuspected bone fracture / breakSuspected dislocationLoss of consciousnessRespiratory problemsSuspected spinal injuryAllergic reactionOther
Does the individual have a known history of asthma?

YesNo
Does the individual have a known history of anaphylaxis?

YesNo
Body part injured (please select all that apply)*

Head/EyeShoulder/ArmWrist/HandChest/AbdomenHip/Groin/ThighLeg/KneeAnkle/FootOther
Has the student displayed any signs of concussion?*

Signs of concussionNo signs of concussionN/A
You have selected that the student displayed signs of concussion. Please ask their parent, guardian or coach to scan the following QR code to receive the IGSA Sport Concussion Notification Form
How did the injury occur?*

Contact with a fixed object (e.g. wall, goal post)Contact with another personContact with an object (e.g. ball, hockey stick)Trip / FallOther non-contact injury (e.g. running, change of direction)Other
Nature of injury?*

New injuryPrevious injury from other term/sPreviously injured this termOther
Did the student return to play/activity?*

YesNo
Was any follow up action recommended?*
If other, please list the recommended follow up action*
Please provide any further information that is relevant to the injury
Name of person completing form*

First NameLast Name
Name for form - do not edit or remove
Email for form - do not edit or remove
Should be Empty:

Accident/Injury Report Form