MTAS Injury Report Form

Injury Report Form
Steward to report all injuries requiring hospitalisation to ausclaimsmotorcycle@dwfgroup.com to MA on legal@ma.org.au before 8am next business day. In the event of a death contact the local police and SMS details to Peter Doyle on 0439 994 954 immediately.
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Time
Event
Permit No.
Discipline
Club Name
Venue
Other

Other
Class
Bike No
Location / Turn
Racing Stopped
Arived At Medical Centre By

FIV Ambulance Other
Injuries
Summary of Injuries
Medical Clearance Required
Referred to(name)
Patient Details
Patient Name
MA Licence Number
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Event and Incident Details
Phone Number
Format: (000) 000-0000.
Emergency Contact person
Medical Background Concurrent Illnesses and Previous Operations
CurrenMedication
Tetanus UTD
Allergies
BP
Heart Rate
GCS
SpO2
Relevant Presentation / Examination / Treatment Detail
Describe any marks to helmet
Type of activity at time of injury

Other
Type a question

Other
What parts of body were injured?
Nature of injury/illness

Other
Provisional diagnosis/es
Mechanism of injury

Other
Was protective equipment worn on the injuredbody part?
If yes, what type eg helmet, neckbrace
Initial Treatment

Other
Advice Given
Critical Incident
Referral

Other
Provisional severity assessment
Treating Person

Other
Form Completed By
Name
Organisation
Signature
Contact Number
Date / Time

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
INJURY REPORT FORM
Patients Name
Protective Equipment
Tick or circle body part/s injured & name
Name of Medical Service Provider
Form Completed By (please repeat for second page):
Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Role
Signature
Should be Empty:

Injury Report Form

Patient Details

Event and Incident Details

Form Completed By

INJURY REPORT FORM

Protective Equipment

Form Completed By (please repeat for second page):