MTAS Injury Report Form

Injury Report Form
Steward to report all injuries requiring hospitalisation to motorcycle@proclaim.com.au 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
Date
Time
Event
Permit No.
Discipline
Club Name
Venue
Other

CompetitorSpectatorOfficialOther
Class
Bike No
Location / Turn
Racing Stopped

YesNo
Arived At Medical Centre By

Arrived at Medical Centre by:FIV Ambulance OtherRacing StoppedWalk InFIV Ambulance Other
Injuries

YesNo
Summary of Injuries
Medical Clearance Required

YesNo
Referred to(name)
Transported to by Private CarAmbulance HelicopterReferred to(name)
Patient Details
Patient Name
MA Licence Number*
Date of Birth

MonthDayYear
Date
Address
Event and Incident Details
Phone Number
Emergency Contact person
Medical Background Concurrent Illnesses and Previous Operations
CurrenMedication
Tetanus UTD

YesNo
Allergies
BP
Heart Rate
GCS
SpO2
Relevant Presentation / Examination / Treatment Detail
Describe any marks to helmet
Type of activity at time of injury

PracticeCompetitionRecreationalOther
Type a question

New Injuryexacerbated/aggravated injuryrecurrent injuryIllnessOther
What parts of body were injured?
Nature of injury/illness

abrasion/grazesprain e.g. ligament tearstrain e.g. muscle tearopen wound/laceration/cutType obruise/contusionption 5inflammation/swellingdislocation/subluxationoveruse injury to muscle or tendonblistersType option 10Type option 11Type option 12Type option 13Type option 14unspecified medical conditionOther
Provisional diagnosis/es
Mechanism of injury

High SideLow SideImpactHit wall / barrier / objectOverexertion (eg muscle tear)OveruseSlip/TripTemperature related eg. Heat stressJumpHigh SpeedMedium SpeedLow SpeedOther
Was protective equipment worn on the injuredbody part?

YesNo
If yes, what type eg helmet, neckbrace
Initial Treatment

None given (not required)RicerTaping onlySling or splintCPRNone given (referred elsewhere)DressingCrutchesStretch/ExercisesOther
Advice Given

Immediate return, unrestricted activityAble to return with restrictionUnable to return at the present timeRider able to return but chose not toReferred for further assessment beforereturning to activity
Critical Incident

YesNoWere Police involved?Was a coroner involvedNA See Referral
Referral

no referralmedical practitionerphysiotherapistambulance transporthospital (private car)helicopterOther
Provisional severity assessment

mild (1-7 days modified activity)moderate (8-21 days modifiedactivity)severe (>21 days modified or lost)
Treating Person

medical practitionerfirst aid providerOther
Form Completed By
Name
Organisation
Signature
Contact Number
Date / Time

MonthDayYear
Date
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
Date
Role
Signature

Clear
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):