People Details

Coach/Individual in Charge Details

Name

Tel. Number

Address

Post Code

About the injured person

Full Name

Tel. Number

Address

Post Code

Sex

Age

Incident Details

About the Incident

Activity taking place at the time of incident:

Date of Incident

Place of Incident

Photo of area where incident took place (if appropriate)

Description of Incident:

Action Taken

Action taken by Coach/Leader/Club rep:

Were the Emergency Services called?

If Yes, provide details:

Action taken by Doctor or Nurse (if applicable):

Diagnosis:

Signatures

Signature of Coach/Leader/Club Rep
Signature of Casualty (if possible)
Signature of witness (1)

Address

Signature of witness (2)

Address

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.