(Including Incident/Injury/Player Send Off)
Confidential
This form must be FULLYCOMPLETED by the affected player in conjunction with team coach/manager.
WITHIN 24 HOURS of the incident, either hand deliver to the Club Secretary @ 49 Downing St Epping 2121 or email to
Incident ReportComplete where applicable
NATURE OF INCIDENT / Injury/Illness Player send Off
AFFECTED PERSON / Player official member of the Public
LOCATION OF INCIDENT
Field/Ground / Date / Time
Opposition / Grade
Game / Home Game Away Game / Ground Condition / Wet Dry
Referee
DETAILS OF INJURED PERSON
Players/Persons Name / Playing Position
Date of Birth / Gender / M F
Contact Details / Home Phone / Mobile
Address
Email address
Coaches Name / Mobile
INCIDENT DETAILS
When did the incident occur: / Before the Game / During the Game / After the Game
On the Playing Field / At the Park / Other
Who was involved? / Self Another player Referee Spectator Other
Opposition players name involved in incident / Opposition player shirt number
Were there any witnesses? Yes No
Name / Phone
Name / Phone
What happened? (Please print clearly. Include information on how and what lead to the injury and/or issue of a Red Card. State the tone and language used during the incident.)
(Attach any other relevant statements from players or witnesses on a separate sheet).
INCIDENT ATTRIBUTED TO:
Opposition / Weather Conditions / Spectator / Accidental
Language / Referee / Field Conditions / Tackling technique
Over reaction of Referee / Racist comments / Verbal abuse / Discrimination
Other (specify)
INJURY SUSTAINED:
Fingers / Arm / Elbow / Toe / Foot
Leg / Knee / Back / Neck / Head
Eye / Face / Grazed skin / Cut / Blood
Other (specify)
NOTIFICATION
Player/Coach/ Manager signature / Date
Player / Coach / Manager / Other - Specify
Page 1 of 2
/home/pooranee/Desktop/EEW_Incident_Report_Form.doc