Site where incident/accident took place

Name of person in charge of session/competition

Name of injured person

Address of injured person

Post Code

Tel No.

Date and time of incident/accident

Date

Time

Nature of incident/accident

Give details of how and precisely where the incident/accident took place.   Describe what activity was taking place, e.g. training game, getting changed, etc.

Give full details of the action taken including any first aid treatment and the name(s) of the first aider(s):

Were any of the following contacted:

Police

Yes      o

No        o

Ambulance

Yes      o

No        o

Parent/carer

Yes      o

No        o

What happened to the injured person following the incident/accident? (e.g. went home, went to hospital, carried on with session)

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