Accident/Incident Report Form
Please send to: firstname.lastname@example.org
St. Marys and Area Minor Soccer Club Incident / Accident Report
Game (Home Team): ___________________ VS. (Away Team) ________________
Played At: ___________________________ Date: ______________________
1. Name of injured person:
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
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:
9. What happened to the injured person following the accident?
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.
Name (Print): _________________ Date: ___________________