Rugby 365 Accident /Incident Form

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* 1. Which Rugby 365 AGP did the accident/incident occur?

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* 2. Date and time of when the alleged accident/incident occurred?

Date / Time

Date

Time

AM/PM

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* 3. Contact information for injured person

Name

Email Address

Phone Number

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* 4. Details of Incident (Example - player was stood on by opposition boot in the ruck. Boot came down on players head and the stud caught the top of the head.)

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* 5. Apparent Injuries? (Example - Open cut to the head with visible bruising and swelling.)

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* 6. Treatment given and by whom? (Example - John Smith club Physio/RFU first aider washed and cleaned wound with saline solution and removed any containments using sterile tweezers.)

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* 7. Was an ambulance emergency service called?

Yes

No

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* 8. Was the injured person then taken from site to hospital?

Yes

No

If you answered yes which hospital did they go to?

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* 9. Details of person completing form

Name

Email Address

Phone Number