ࡱ> UWRST%` FbjbjNN Q,,4"...T///0|2td*~3<:<:<:T:=?vAocqcqcqcqcqcqc$gh6jc.@F<<^@F@Fc<:T:N^d N N N@F8<:.T:oc N@Foc N N_\h.S]<:r3 pY}΋/FG\octd0d\|jHj S]j.S]>BHC NpD,E>B>B>BccM^>B>B>Bd@F@F@F@FFF Fax or Email to ARU at (02) 8005 5681 / communityrugby@rugby.com.au and the State Union A Serious Injury Report must be completed for the following match or training related injuries: ANY HEAD OR NECK INJURY THAT RESULTS IN A PLAYER BEING TREATED AT AN EMERGENCY DEPARTMENT, HOSPITAL OR AFTER-HOURS MEDICAL CENTRE, OR ANY INJURY THAT RESULTS IN THE ADMISSION OF A PLAYER INTO HOSPITAL. How to submit this report: Accurately record details about the player, their injury, the match and the designated club/school contact below. " Email or fax within 48 hours of the time of incident to both the Australian Rugby Union and the State Union. PLAYER (PLEASE PRINT CLEARLY) Name (in full):  FORMTEXT       Date of Birth:  FORMTEXT    /  FORMTEXT    /  FORMTEXT    Age:  FORMTEXT    Address:  FORMTEXT       Phone Number: ( FORMTEXT   )  FORMTEXT       FORMTEXT      Next of Kin:  FORMTEXT       Phone Number: ( FORMTEXT   )  FORMTEXT       FORMTEXT      Club/School:  FORMTEXT       Playing Position:  FORMTEXT       INJURY Date and Time of Injury:  FORMTEXT    /  FORMTEXT    /  FORMTEXT    at  FORMTEXT    :  FORMTEXT    AM  FORMCHECKBOX  PM  FORMCHECKBOX  Scene of injury: Game  FORMCHECKBOX  Training  FORMCHECKBOX  Other  FORMCHECKBOX  Site of Injury: Head  FORMCHECKBOX  Neck  FORMCHECKBOX  Back  FORMCHECKBOX  Chest/Trunk  FORMCHECKBOX  Other  FORMCHECKBOX  (specify):  FORMTEXT       Type of Injury: Concussion  FORMCHECKBOX  Fracture  FORMCHECKBOX  Dislocation  FORMCHECKBOX  Serious Joint  FORMCHECKBOX  Other  FORMCHECKBOX  (specify):  FORMTEXT       Phase of Play: Tackle  FORMCHECKBOX  Ruck  FORMCHECKBOX  Maul  FORMCHECKBOX  Scrum  FORMCHECKBOX  Lineout  FORMCHECKBOX  Other  FORMCHECKBOX  (specify):  FORMTEXT       Stage of Game: 1st Qtr  FORMCHECKBOX  2nd Qtr  FORMCHECKBOX  3rd Qtr  FORMCHECKBOX  4th Qtr  FORMCHECKBOX  Was the player wearing headgear?: Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT       Brief description of how the injury occurred: Did the player leave the field? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Did the player return to the field? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Who provided on-field treatment? Doctor  FORMCHECKBOX  First Aid  FORMCHECKBOX  Team Official  FORMCHECKBOX  Other  FORMCHECKBOX  (specify):  FORMTEXT       Name of treatment provider:  FORMTEXT       Phone Number: ( FORMTEXT   )  FORMTEXT       FORMTEXT      What treatment was provided, if any?  FORMTEXT       How did the player leave the field? Stretcher  FORMCHECKBOX  Ambulance  FORMCHECKBOX  Helicopter  FORMCHECKBOX  Other  FORMCHECKBOX  (specify):  FORMTEXT       What hospital was the player taken to?  FORMTEXT       Phone Number: ( FORMTEXT   )  FORMTEXT       FORMTEXT      Who accompanied the player?  FORMTEXT       Phone Number: ( FORMTEXT   )  FORMTEXT       FORMTEXT      MATCH Teams involved in the match:  FORMTEXT       v  FORMTEXT       Competition:  FORMTEXT       State Union:  FORMTEXT       Grade:  FORMTEXT       Referee:  FORMTEXT       Phone Number: ( FORMTEXT   )  FORMTEXT       FORMTEXT      Venue Address:  FORMTEXT       Field Condition:  FORMTEXT       Weather Condition:  FORMTEXT       How long was the game suspended for?:  FORMTEXT     mins Did the game restart?: Yes  FORMCHECKBOX  No  FORMCHECKBOX  Is there video footage of the game?: Yes  FORMCHECKBOX  No  FORMCHECKBOX  (If yes, please retain until contacted by the ARU) CLUB/SCHOOL CONTACT Name (in full):  FORMTEXT       Position in Club/School:  FORMTEXT       Contact Numbers: Home: ( FORMTEXT   )  FORMTEXT       FORMTEXT      Mobile:  FORMTEXT       FORMTEXT      FORMTEXT     Work: ( FORMTEXT   )  FORMTEXT       FORMTEXT      Signature:  FORMTEXT       Date:  FORMTEXT    /  FORMTEXT    /  FORMTEXT    State Union Fax Numbers ACT & SNSW Fax (02) 6260 8591 Queensland Fax (07) 3856 6333 Victoria Fax (03) 9529 7156 New South Wales Fax (02) 9323 3470 South Australia Fax (08) 8231 8066 Western Australia Fax (08) 9387 2804 Northern Territory Fax (08) 8945 2060 Tasmania Fax (03) 6228 0855 ARU Protocol for Serious Injury In the event of a serious injury to a players head or neck (ie: suspected spinal injury) or fatality, the following protocol is to be followed: 1. Provide immediate on-field medical care and arrange suitable transportation (ie. ambulance) to the hospital for the injured player. 2. Club representative to phone the ARU Serious Injury Case Manager (SICM) on the ARU Hotline 1800 036 156 in the event of a serious injury (ie: suspected spinal injury or fatality). This number is a call back service and your details will be passed on to the SICM who will call you back ASAP. Please have all details of the incident ready to pass on to the SICM. 3. 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,h!ihmFCJOJPJQJ^JaJmH sH ,h!ih>CJOJPJQJ^JaJmH sH ,h!ih>CJOJPJQJ^JaJmH sH 6jh#CJOJPJQJU^JaJmHnHsH u/jh#CJOJPJQJU^JaJmH sH ;j2hh#CJOJPJQJU^JaJmH sH  N'P'R'\'^'`'j'r't'''''ɭɖgS5gS;j3hlz^hCJOJPJQJU^JaJmH sH &hCJOJPJQJ^JaJmH sH /jhCJOJPJQJU^JaJmH sH ,h!ih>CJOJPJQJ^JaJmH sH ,h!ihmFCJOJPJQJ^JaJmH sH 6jhmCJOJPJQJU^JaJmHnHsH u/jhmCJOJPJQJU^JaJmH sH ;j3hmhbCJOJPJQJU^JaJmH sH  '''''''''''''''''ս՟սՁjP;)h)WhB*CJOJQJ^JaJph2h!ih75CJOJPJQJ\^JaJmH sH ,h!ih>CJOJPJQJ^JaJmH sH ;j4hlz^hCJOJPJQJU^JaJmH sH ;j 4hlz^hCJOJPJQJU^JaJmH sH /jhCJOJPJQJU^JaJmH sH &hCJOJPJQJ^JaJmH sH ,hV`hCJOJPJQJ^JaJmH sH ''''((((()+)/)0)1)w$d,7$8$H$a$gd,h 7$8$H$gd,h$d7$8$H$a$gd$qd7$8$H$]gd$q d7$8$H$gd$d7$8$H$a$gd< 7$8$H$gd)W d,7$8$H$gdwJ&d7$8$H$Pgd7 H7$8$H$gd, '((((((2(3(R(S(p({((jS<(<(<&h$q5B*CJOJQJ^JaJph,hh$q5B*CJOJQJ^JaJph,hh5B*CJOJQJ^JaJph,hh5B*CJOJQJ^JaJph,hh5B*CJOJQJ^JaJph&h5B*CJOJQJ^JaJph)h]hh)WB*CJ OJQJ^JaJ ph&h)W5B*CJOJQJ^JaJph&hDk5B*CJOJQJ^JaJph,hhwJ5B*CJOJQJ^JaJph (((((())*)+).)/)0)1)2)黤ygWB*/h)Wh,h5CJOJPJQJ^JaJmH sH )hUXh,hB*CJ OJQJ^JaJ phh,hCJOJQJaJmH sH #h,hB*CJOJQJ^JaJph&h$q5B*CJOJQJ^JaJph,hh$q5B*CJOJQJ^JaJph,h$qhc5B*CJOJQJ^JaJph,h$qh$q5B*CJOJQJ^JaJph,h$qh5r 5B*CJOJQJ^JaJph,h$qh5B*CJOJQJ^JaJph1)2)R)S))j*+lJ246vx@ d,7$8$H$gdR+^$d7$8$H$NgdR+^ 7$8$H$gdR+^$d,7$8$H$a$gdR+^$d,7$8$H$a$gd,h d,7$8$H$gd,h h$d7$8$H$Ngd,h2)R)S)t)))))))))))2*B*j*m***ԿtbM;MM#h1 B*CJOJQJ^JaJph)h7^Dh,hB*CJOJQJ^JaJph#h7|B*CJOJQJ^JaJph#h.B*CJOJQJ^JaJph)h7^DhR+^B*CJOJQJ^JaJph#hR+^B*CJOJQJ^JaJph#h 5JB*CJOJQJ^JaJph)h7^Dh,hB*CJOJQJ^JaJph)hVSh,hB*CJOJQJ^JaJph,hVSh,h5B*CJOJQJ^JaJph*****+++c+d+++lrVXJP024ԿԁԿԿԿԿԿl\hR+^CJOJQJaJmH sH )hUXh,hB*CJ OJQJ^JaJ phU)h7^DhR+^B*CJOJQJ^JaJph)hR+^hR+^B*CJOJQJ^JaJph#h,hB*CJOJQJ^JaJph)h7^Dh,hB*CJOJQJ^JaJph)h7^Dh,hB*CJOJQJ^JaJph,hRsh,h5B*CJOJQJ^JaJphSICM to establish initial contact with designated hotline caller to ascertain current status. 4. SICM notifies ARU General Manager (GM) of Community Rugby or designate of situation. 5. SICM or GM notifies designated representative responsible for zone/region/state union (eg: New South Wales Country Rugby  Executive Officer). 6. Designated representative responsible for zone/region/state is to establish one point of contact with the club/zone to coordinate situation (eg: President/Executive Officer). 7. SICM or GM to notify ARU Media Manager. 8. SICM, GM and representative responsible for the zone/region/state to establish a process of support as required. ARU Serious Injury Case Manager The Australian Rugby Union (ARU) has appointed a Serious Injury Case Manager (SICM), to assist the club in managing traumatic injuries. The SICM is your first point of contact in the event of a serious injury to a players head or neck (ie: suspected spinal injury) or fatality and will provide a link between the club and the Australian Rugby Union (ARU). Club/School Responsibilities 1. Provide immediate on-field medical care and arrange suitable transportation (ie. ambulance) to the hospital for the injured player. 2. Phone SICM on the ARU Hotline 1800 036 156 in the event of a serious injury (ie: suspected spinal injury or fatality), who in turn notifies ARU nominee. 3. Phone zone/regional/governing affiliate administration. 4. Accurately record any details and persons associated with the injury. 5. Notify next of kin in the case of a serious injury to a players head or neck. 6. In the case of a fatality, the Police will notify the next of kin. 7. Monitor players/match officials (referees, touch judges)/club officials (coaches, managers, runners, trainers, physiotherapists etc) for team debrief and/or personal counselling. 8. Complete the Serious Injury Report (on the back of this page) and provide copies within 48 hours of the injury occurring to:- (1) Australian Rugby Union  Fax (02) 8005 5681 or Email communityrugby@rugby.com.au (2) State Union  ACT & SNSW Fax (02) 6260 8591 Queensland Fax (07) 3856 6333 Victoria Fax (03) 9529 7156 New South Wales Fax (02) 9323 3470 South Australia Fax (08) 8231 8066 Western Australia Fax (08) 9387 2804 Northern Territory Fax (08) 8945 2060 Tasmania Fax (03) 6228 0855 9. Complete the ARU Sports Injury Claim Form for all insurance claims. For more information please contact Gow-Gates Insurance Brokers (1800 811 371) or visit www.rugby.com.au/communityrugby State Union Responsibilities 1. Follow up counselling requirements for the injured player, club personnel, referee and touch judges in conjunction with SICM and GM. 2. In conjunction with club/school officials, zone/regional/governing affiliate administration and ARU, handle all media contact. There should be one point of contact for media releases. 3. State Union representative to attend any inquest/event. 4. Assist (with club) any fund raising activities as required. ARU Responsibilities 1. Provide support  (logistical and human) to the injured player, family, club, match officials and state union as required. 2. Monitor current and ongoing status of the injured player. 3. Complete analysis report of injury occurrence and record on the ARU Serious Injury Register. 4. Maintain ARU database.     Serious Injury Report Note, this report IS NOT an ARU Sports Injury Claim Form. 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