Scholar Victoria Injury Report Form
Coaches without medical training should refer all medical decisions to appropriately qualified persons.  Do not attempt to 'diagnose' an injury. Users of this form are advised that information collected is confidential and subject to normal management of health records.
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Date of injury (if filling out form later)
MM
/
DD
/
YYYY
Time of injury (if filling out form later)
Time
:
Name of injured person *
Age of Injured Person (optional - to assess adult/child etc)
Gender
Clear selection
Role of injured person
Name of first aid provider *
Was an ambulance required? *
Nature of Injury *
Did the person return to activity immediately?
Clear selection
Suspected nature of injury (not a diagnosis)
Treatment
Brief description of injury (injury location, type of injury, treatment, recommendation for medical follow up etc)
How did the injury occur
Brief description of circumstance of injury *
Name of person completing this form *
Submit
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