Serious Injury Report (2020)
Serious injury reports must be completed for the following injuries:

- Any head or neck injury that requires the player to be transported directly from the ground to an emergency department, hospital or after hours medical centre
- Any injury that results in the admission of a player into hospital after the game
- Any injury that is expected to prevent a player from playing for a period of 8 weeks or longer

Serious injury reports must be completed within 48 hours of the injury coming to the notice of the referee or team management
Sign in to Google to save your progress. Learn more
Injured person first and last name *
Player's club/school *
Player's NZ Rugby number (if known)
Date of birth - Provincial Union/Club responsibility
MM
/
DD
/
YYYY
Gender *
Playing Position * *
Player's Grade *
Contact Details of Person Completing Form
First name and Last name *
Club Email Address - this will be where your injury report will be sent to *
Mobile *
Home phone
Designation - Referee, Team Manager *
Club / School
Provincial Union *
Give a short description of the law
Location details
Date *
MM
/
DD
/
YYYY
Time
Time
:
Place
The injury occurred during
Type of injury *
Required
Event causing injury *
Required
Injury site *
Required
Blue card *
Treatment details
On-field treatment provider *
Required
Method of leaving field *
Required
Brief description of how the injury occurred *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Sport Gisborne Tairāwhiti. Report Abuse
Google Forms