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Accident & Injury report
Personal Details
Name of Injured Person
(Required)
First
Last
Club / Team / Division
(Required)
Contact Number
(Required)
Position
(Required)
Player
Official
Staff
Spectator
Visitor / Contractor
Other
If other, please advise:
(Required)
Name of Witness
(Required)
First
Last
Contact Number of Witness
(Required)
Incident Details
Nature of Incident
(Required)
Near miss
Accident
Hazard
Other
If other, please advise:
(Required)
Date
(Required)
Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Venue of Incident
(Required)
Description of Incident
(Required)
Who has been notified?
(Required)
Nature of Injury or Equipment Damage
Nature of Injury or Damage
(Required)
Part of Body Affected (if applicable)
What First Aid was Administered?
(Required)
Who attended to the Injury?
(Required)
Describe any other action taken:
Investigation
Name of Investigating Officer
(Required)
First
Last
What contributed to the incident?
(Required)
Equipment or Building
Environmental
Human
Provide Details:
(Required)
Describe any immediate action taken to eliminate further risk / stabalise situation:
(Required)
Describe any actions recommended to prevent a recurrence:
(Required)
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1300 316 555