Incident and Accident Report
Please complete this form with all relevant details and give to the Centre Manager
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City & Postocde
Contact Number
Email Address
Role at netball
eg - player, umpire, spectator, volunteer, coach, manager, staff etc
Type of Play:
Premier
Representative
Holiday Programme
Saturday Netball
Development Programme
ANZ FutureFERNS
Fast 5
Saturday Netball
Other
Club/School affiliated to (if applicable)
Name of person reporting:
Date/Time of incident
Location of Incident/Accident
PARTICULARS OF INCIDENT: (What happened?)
Name of Witness (if applicable)
TYPE OF INJURY
Strain/Sprain
Laceration/Cut
Scratch/Abrasion
Foreign Body
Bruising
Amputation
Burn/Scald
Dislocation
Chemical reaction
Type of injury - Other (Please describe):
BODY PART
Head/Neck
Hand
Upper Limbs
Trunk
Lower Limbs
Back
If reporting a NEAR MISS, what do you think caused the near miss? (procedure, staff, equipment etc):
TREATMENT OF INJURY
Nil
First Aid
Doctor
Hospitalised
Name of First Aider:
Any improvement or consideration required by NNC
Submit
Should be Empty: