Accident/ Incident Reporting Form



Accident/Incident Report Form 

Please send to: stmarysminorsoccer@gmail.com

 

St. Marys and Area Minor Soccer Club Incident / Accident Report

Game (Home Team): ___________________   VS.  (Away Team) ________________

Played At: ___________________________           Date: ______________________

 

1. Name of injured person:  

___________________________________________

OSA#: ___________________________

 

2. Address of injured person:  

__________________________________________________________________

 

3. Location where accident took place (click all that apply):  

  • On the field

  • In the parking lot

  • In the change room

  • Before the game

  • During the first half

  • During the second half

  • After the game

  • Other ____________________

 

4. Name of person(s) involved (coaches, officials, spectators):

______________________________________________________________________________________________________________

5.  The person had:

  • No loss of consciousness

  • Loss of consciousness

 

6. Give details of how the incident took place. Describe what activity was  taking place, nature of the accident or injury. 

______________________________________________________________________________________________________________

 

7. Give details of the action taken including any first aid treatment and the name(s) of the  first-aider(s).  

______________________________________________________________________________________________________________

 

8. Indicate which of the following contacted:  

  • Police  

  • Ambulance  

  • Parent/ Guardian  

 

9. What happened to the injured person following the accident?

  • Went home

  • Went to hospital

  • Carried on with session

  • Removed from location in an ambulance

 

 All of the above facts are a true and accurate record of the incident/ accident.  

Signed: ____________________________ 

Name (Print): _________________ Date: ___________________





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