Accident / Injury Report Form

Accident / Injury Report Form

STRICTLY CONFIDENTIAL
Coach Name

First NameLast Name
Job Role
For example: Lead Coach
School / Venue Name
Date of Accident / Injury

MonthDayYear
Date
Time of Accident / Injury (approx.)

Hour Minutes

AM/PM Option
Location of accident / injury
For example: Sports hall
Name of Injured Child

First NameLast Name
Gender
Nature of injury
Body part affected
Was there bleeding?
Was the child conscious throughout?
Has first aid been provided?
Who provided first aid? (N/A if no first aid)

First NameLast Name
First Aid Administered
Provide details of accident / injury
Please provide a detailed, factual account of what happened. Include any relevant objects, equipment, or circumstances as well as witnesses
Follow up action?
Who has been informed?
Would the informed person require a copy of this report
If YES to the above please provide an email. (N/A if NO)
example@example.com
Name of person informed

First NameLast Name
Declaration: I, the undersigned parent/guardian of the child named in this report, acknowledge that I have been fully informed of the nature of the incident and the action taken by the SportsCool staff. I have been offered a copy of this report.
Signature of person informed
Should be Empty: