EmailMe Form - HERTFORDSHIRE CRICKET ACCIDENT REPORT FORM

CONTACT INFORMATION

Responsible Adult

Name of Coach / Staff Member / Volunteer in attendance *

First Last

Email Address *

Contact Tel No *

INJURED PERSON INFORMATION

Child / Young Person

Name *

First Last

Age Group Squad *

Date of Birth

DD / MM / YYYY

Gender *

If Another Description - please state

Has the child / young person returned to training / matches following the accident?

No

Yes

ACCIDENT INFORMATION

Please complete all sections

Date of Accident *

DD / MM / YYYY

Time of Accident *

HH : MM AM/PM

Who reported the accident? *

First Last

Location of Accident *

Details of Injury *

Nature of and how accident happened *

Did anyone witness the accident? *

No

Yes

If Yes give - please give name(s) and details of witness(es)

Was first aid administered? *

No

Yes

If Yes - please give details

Did the injury require additional assistance from the Emergency Services *

No

Yes

If Yes - please give details

Have parents / guardians / carers been notified? *

No

Yes

If Yes - please state by whom and when

Recommended action to be taken by the injured player *

Any additional information you would like to add to the report in regards to this accident?

Form Completed by *

First Last

Dated *

DD / MM / YYYY