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C & F HC Incident/Accident Reporting Form
This form should be used to record any incidents or accidents that occur during training or at any matches or tournaments
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* Indicates required question
Email address
*
Your answer
Your name
*
Your answer
Your role
*
Your answer
Your contact details
*
Your answer
Injured Person's name
*
Your answer
Team
*
Your answer
Date of Incident
*
MM
/
DD
/
YYYY
In what type of Match/Training did the injury take place?
*
Adult Match
Junior Match
Adult Training
Junior Training
Did the injury occur during a Penalty Corner or Open Play?
Penalty Corner
Open Play
Clear selection
What was the injury caused by? If 'Other' please specify
Ball
Stick
Body
Other:
Clear selection
Did the injury require hospital treatment?
Yes
No
Clear selection
What part of the body was affected?
Head
Neck
Face
Upper Body
Lower Body
Clear selection
What was the type of injury sustained? If 'Other' please specify
Concussion
Fracture/Break
Sprain/Strain/Ligament/Tendon
Bruising/Wound
Other:
Clear selection
What, if any, protective equipemnt was worn at the time of injury? Please select all that apply. If 'Other' please specify
Face Mask
Gum Shield
Shin Pads
Other:
Please provide us with some brief details of the injury
*
Your answer
Parent/carer contact details (if under 18)
*
Your answer
Have their parents/carers been informed?
Yes
No
Clear selection
Submit
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