Question Title

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

Date / Time

Question Title

* 3. Contact information for injured person

Question Title

* 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.)

Question Title

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

Question Title

* 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.)

Question Title

* 7. Was an ambulance emergency service called?

Question Title

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

Question Title

* 9. Details of person completing form

T