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Home
About
About Us
Clubhouse/Pavilion
Pitch Calendar
The HHC Board
Coaches
Photographers
Cup Holders
Club Policies, Rules & Procedures
Junior Rules/Policies/Procedures
Men’s
Men’s Teams
Adult Training
Pitch Calendar
Ladies
Ladies Teams
Adult Training
Pitch Calendar
Back to Hockey
Junior
Junior Squads
Coaching Philosophy
Junior Gallery
Junior Club Guide
Junior Player – Selection Policy
Junior Cup Holders
Membership 2022/3
Membership 2022/3
Teamo HELP!
Kit
Updates
Contact
Sports Injury Report Form
Step
1
of
3
33%
Name of Person Injured
*
Date of Birth *
*
DD slash MM slash YYYY
Gender *
*
Gender*
Male
Female
Phone Number
Address
Person injured
*
Player
Coach
Date/ time of Incident: *
*
DD slash MM slash YYYY
Time of Incident: *
*
:
Hours
Minutes
Did it occur during
*
Training
Game
Location of incident :
*
Name of First Aider:
Phone Number of First Aider :
Witness :
Phone Number of Witness :
Details of Incident:
Body Part Injured
Click
image to download then can draw above the picture and upload
Upload body part injured image
Max. file size: 2 MB.
Type of Injury
Type of Injury
Was an Ambulance Called *
*
Was an Ambulance Called *
Yes
No
Head Injury
Please state:
Did the person loose consciousness
Did the person loose consciousness
Yes
No
Conscious level
Conscious level
A
V
P
U
Is Concussion suspected
Is Concussion suspected
Yes
No
Was CPR Performed
Was CPR Performed
Yes
No
Was an AED used
Was an AED used
Yes
No
How many Shocks were given
Additional Information:
Follow up Action
Follow up Action
None
Medical Professional
Hospital - (which hospital )
Released into Parental Care / Guardian (U18)
Please state name of person
Refused Treatment—Signature
Reset signature
Signature locked. Reset to sign again
Name of Person Filling in form: *
*
Signature of Person Filling in form:
*
Reset signature
Signature locked. Reset to sign again
Note:
Coaches without medical training should refer all medical decisions to an appropriate qualified person.
DO NOT
attempt to diagnose an injury. This form contains Confidential Information and should not be disclosed to anyone not having authority.
After Incident:
Report and discuss follow up actions with:- • Director of Junior Hockey
juniors@haslemerehockey.com
and Child Welfare Officer
cwo@haslemerehockey.com
for all incidents involving U18s. • or Director of Hockey,
dh@haslemerehockey.com
. • Send completed form to Director of Junior Hockey or Director of Hockey.
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
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