"Accident or Serious Incident Report Form - Grand Island Soccer Club" - New York

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Download "Accident or Serious Incident Report Form - Grand Island Soccer Club" - New York

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Accident or Serious Incident Report Form
Team (Age, Gender, Team Name): _________________________________________________________
1. Site where accident took place: __________________________________________________________
2. Name of person in charge of session/competition: ___________________________________________
3. Name of injured person: ________________________________________________________________
4. Address of injured person: ______________________________________________________________
5. Date and time of incident/accident: _______________________________________________________
6. Nature of incident/accident: _____________________________________________________________
_______________________________________________________________________________________
7. Give details of how and precisely where the accident/incident took place. Describe what activity was
taking place e.g. training programme, getting changed etc.
_______________________________________________________________________________________
_______________________________________________________________________________________
8. Give full details of the action taken including any first aid treatment and the name(s) of the first
aider(s)
_______________________________________________________________________________________
_______________________________________________________________________________________
9. Were any of the following contacted?
Ambulance
Yes
No
Parent / Guardian
Yes
No
10. What happened to the injured person following the accident/incident?
(E.g. went home, went to hospital, carried on with session)
_______________________________________________________________________________________
11. Declaration: All of the facts are a true and accurate record of the incident/accident.
Signed ___________________________Print Name ______________________________________
Position __________________________ Date ___________________________________________
Accident or Serious Incident Report Form
Team (Age, Gender, Team Name): _________________________________________________________
1. Site where accident took place: __________________________________________________________
2. Name of person in charge of session/competition: ___________________________________________
3. Name of injured person: ________________________________________________________________
4. Address of injured person: ______________________________________________________________
5. Date and time of incident/accident: _______________________________________________________
6. Nature of incident/accident: _____________________________________________________________
_______________________________________________________________________________________
7. Give details of how and precisely where the accident/incident took place. Describe what activity was
taking place e.g. training programme, getting changed etc.
_______________________________________________________________________________________
_______________________________________________________________________________________
8. Give full details of the action taken including any first aid treatment and the name(s) of the first
aider(s)
_______________________________________________________________________________________
_______________________________________________________________________________________
9. Were any of the following contacted?
Ambulance
Yes
No
Parent / Guardian
Yes
No
10. What happened to the injured person following the accident/incident?
(E.g. went home, went to hospital, carried on with session)
_______________________________________________________________________________________
11. Declaration: All of the facts are a true and accurate record of the incident/accident.
Signed ___________________________Print Name ______________________________________
Position __________________________ Date ___________________________________________