JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Please complete this form within 48 hours of the accident/incident taking place. Information will be recorded centrally for three years after the date of the accident.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name of injured person
*
Your answer
Where did the incident/accident take place?
*
Your answer
Name of person in charge at the time of incident/accident
*
Your answer
Nature of the incident/accident
*
Your answer
Give details of how and where the incident/accident took place.
Describe the activity e.g. training, playing match etc
*
Your answer
Give details of the action taken including any first aid treatment and name(s) of the first aider(s).
*
Your answer
Were any of the following contacted?
Please select all applicable
Police
Ambulance
Parent/Guardian
What happened to the injured person after the incident/accident?
*
Your answer
Is any follow up required by the Club? e
.g. Club Welfare Officer.
If yes/maybe the Club will contact you for more information.
*
Yes
No
Maybe
By submitting this form you agree that all of the above are facts and a true and accurate record of the incident/accident.
Form completed by
*
Your answer
Phone number of person completing the form
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
