Ballymackey Football Club

Accident/Injury Report Form

Date__________________
Name of Injured: ____________________________________ Male _____ Female _____
Age of Injured:
________
Date of Accident/Injury: __________________________
Time of Accident/Injury: __________________________
Location Accident Occurred: __________________________

Nature of Injury
Ankle ______
Finger ______
Foot
______
Forearm______
Head ______
Scalp ______
Tooth ______
Wrist ______

Face
Mouth
Nose
Hand
Ear
Knee
Elbow
Other

______
______
______
______
______
______
______
______

Leg
______
Arm
______
Back
______
Shoulder______
Eye
______
Thigh ______
Ribs
______

Probable Cause of Accident

Fall ______

Collision ______

Brief Description of Accident:

Struck by ______

Specify Other ______

Immediate Action Taken

First Aid
Sent to Hospital
Sent to Doctor
Other

______
______
______
______

Emergency Number Available ______

First Aid Kit on Site
______
Refused Attention
______

Person Completing Report

Name
________________________________
Address ________________________________
________________________________
Phone
________________________________
Position _______________ Date ____________

Signature _____________________