Accident/ Incident Reporting Form

Accident/Incident Report Form 

Please send to:


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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