Accident Report Form

The form below should be completed when a club player, referee, coach, or spectator has been involved in a rugby related accident resulting in an injury which has resulted in time off work/school, and/or medical treatment.   Once submitted, the completed form will go by email to Darren Davies, Club Secretary.   The information that is supplied here is needed for the  Mandatory Return Survey of Serious Injuries to the Rugby Football Union.  It is therefore important that it is supplied in good time, and is accurate.  Any questions about how the form should be completed should be directed to Darren Davies (01908 511519) or Ken Rowe (07753 937959).

Background Information

Date of incident                  Time       

Location of incident          Training or a match? Please select..... Match Training  

If a match, opposition      Referee

Person injured

Name                                   Rugby.... Please select..... Player (member) Player (non-member) Coach Referee Spectator Other

Section/Team                  Please select..... Seniors 1st XV Seniors 2nd XV Seniors 3rd XV Womens Vets Colts U17s U16s U15s U14s U13s U12s U11s U10s U9s U8s U7s Other      Age         

If not a club member, address and phone number

Incident description

Witnesses

Injuries

Main area of injury Please select..... Knee/Leg/Foot/Ankle Shoulder/Collar Bone Hand/Arm/Wrist Back Head/Face Concussion Concussion plus other injury Ribs Groin Pelvis/Hips Organic Other Parts Neck

If player, was/he she wearing padding or a head protector?  If so, describe

If neck injury, confirm specific action taken

Other comment re injury

Treatment

Outcome (e.g. time off work/school/playing etc)

Person making the report

Name                             

Email                             

Contact phone             

It is now recommended that you print a copy of this form for your own records before hitting "Submit" below.

Thank you for completing the accident report.