Motorcycling Australia Injury Report Form

• Conducted on

  Date

• Prepared by

• Location on track / premises where incident occurred

• CityMX Management are to email all injuries requiring a medical clearance to MA on mail@ma.org.au before 8am next business day. In the event of a death please contact the local police, and SMS details to Peter Doyle on 0439 994 954 immediately.

Event and Incident Details

• Event (i.e. CityMX, Private Coaching, Manufacturer Day etc)

• Permit No for relevant track (Jr, Int or Main)

  Junior 011120

  Intermediate 021120

  Main 031120

• Discipline (Motocross)

• Promoter (CityMX)

• Venue (CityMX 2-88 Lawrie Emmins Reserve Laverton North VIC 3026)

• Describe the incident

• What is the role of the patient?

  Select Recreational rider Competitor Official Spectator Other

  • Recreational rider
  • Competitor
  • Official
  • Spectator
  • Other

• Provide details

• Location / Turn # (See track maps for details)

• Arrived at Medical by:

  Select Walk in First Intervention Vehicle (FIV) Ambulance Other

  • Walk in
  • First Intervention Vehicle (FIV)
  • Ambulance
  • Other

• Provide details

Injuries

• Was the patient injured?

  Yes

  No

• Summary of Injuries

Patient Details

• Name

• Date of Birth (if known)

  Date

• Address (if known)

• Phone number (if known)

• Emergency contact person or guardian (if known)

Record Damage to Helmet

• Marks / Damage to Helmets

  Drawing

• Add photos if desired

  Media

Form Completed By

• Name

• Signature

  Sign

• Date / Time

  Date