HLNC Incident/ Accident Report Form
Please fill this form in if any player, official or spectator has had an incident whilst being involved with HLNC training/ matches/ events. Submitted forms will be permanently stored in a confidential account (owned by Lucy Masser).
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Name of injured person *
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Name of person in charge of the session, and details of their position *
(E.G. Joe Smith, Coach ; Jane Smith, Umpire)
Address of where the incident took place *
(Including specific area (e.g. on court/ in changing rooms) and postcode. Current home ground address for reference: Hinckley Ladies Courts, Hinckley Rugby Club, Leicester Road, Hinckley, LE10 3DR)
Nature of accident/ incident *
(E.G. suspected broken angle; badly hit head resulting in player feeling dizzy; suspected sprained wrist)
Details leading up to the accident/ incident occurring *
(E.G. player was in C position in a match, ran and jumped to try to intercept a pass and collided with the opposing player; player was using skipping rope in circuits training, caught the rope on their foot and tripped over)
Details of action taken during any first-aid treatment and name(s) of first-aider(s). *
(E.G. ice pack applied to impacted angle by first aider Jane Smith ; bandage applied to affected knee by first aider Joe Smith)
What happened to the injured person following the accident/ incident? *
(E.G. carried on with session; went home; went to hospital)
Were any of the following contacted? *
Required
Names of any other people relevant who witnessed the accident
Name of reporter and date of report *
By signing your name here you are agreeing that all provided facts are a true record of the accident/ incident to your knowledge.(E.G. [Your Name] [Today's date]
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