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Ossett Town Juniors Incident/Accident Report Form
Ossett Town Juniors seek to maintain and uphold the best possible practice and cultivate a culture which maximizes the opportunities to learn and maintain the highest standards. It is not the aim of this form to add unnecessary burden to anyone, nor does it seek to apportion blame.
Reason for Report
Please select
Accident
Incident
An Accident is where any Team Official or player(s) and or any other individual associated with the club such as supporter or parent suffers an injury which inhibits them from returning to normal full activity and or where they require further assessment whilst engaged or participating in an organised event held by the club.
An Incident is when there has been a negative encounter or experience with any aspect to the game of football which has potential effect on an individual, player or team of Ossett Town Juniors. It may wish to highlight negative or unsatisfactory behaviour, potential or actual areas of conflict or where there has been an unacceptable/unfair outcome.
Date & Time of Event
*
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Location where the event took place
*
Activity or Match Details
*
(eg. Training Session, Match Opponents)
Details of Affected Person
Name
*
First
Last
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Details of what happened and actions taken
Please give a brief summary of what happened
*
Please supply as much information as possible including names of first-aiders if relevant
What action was taken, at what time and by whom?
*
What (if any) equipment was used (eg. First Aid)
What happened afterwards?
What was the outcome?
*
Resumed playing
Sent home with advice
A&E (own transport)
A&E (Ambulance)
Please choose one option
Was there any follow-up with the following
*
Medical staff
Parents
Club
Opposition
Police
Media
Other
Tick all that apply
Details of who is completing this form
Name
*
First
Last
Position
eg. Team official / witness
Age Group and/or Team Name
Contact Number
Declaration
*
All of the above facts are a true and accurate record of the incident/accident
The information submitted to the club will be held securely and its contents are NOT for general viewing. The club will treat the information presented in the report with the strictest confidence at all times.
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