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Incident Report Form
Form to report any incidents/injuries within Suburban FC programming. Please contact Keith Toon (Player Safety Coordinator) if you have any questions, concerns, or need to discuss any matters -
playersafety@suburbanfc.ca
.
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* Indicates required question
Location where incident took place:
*
Ex: Charles P Allen Turf Field
Your answer
Date of accident/incident:
*
MM
/
DD
/
YYYY
Approximate time of accident/incident:
*
Time
:
AM
PM
Name of Coach or person in-charge of session/practice/game:
*
Your answer
Role of person in-charge of event (session/practice/game, etc.)
*
Ex: Head Coach, Team Manager, Assistant Coach, Speed & Power Coach, Unknown
Your answer
Name of incident subject / person:
*
Your answer
Team Name, Level and Head Coach:
*
Ex: u15AA Girls, Jane Doe
Your answer
Nature of incident:
*
Describe what happened to the best of your ability / recollection:
Your answer
Give details of how and precisely where the incident took place. Describe what activity was taking place, e.g.training program, during a game, etc. If during a game, give details if a call was made (e.g., red card, penalty kick, etc.).
*
Your answer
Give details of the action taken including any first aid treatment and the name (s) of the first-aider(s) - if any
Your answer
Were any of the following parties contacted? Police, Ambulance, Parent/Guardian. If NO, leave blank. If YES, provide details:
Your answer
What happened to the person following the incident? (e.g. went home, went to hospital, carried on with session)
*
Your answer
Name of person submitting report:
*
Your answer
Email of person submitting report:
*
Your answer
Phone of person submitting report:
*
Your answer
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