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Accident / Incident Report Form
Location of accident/incident:
Date:
Name of Injured Person:
Address:
Name of Team manager or coach:
Nature of incident/injury and extent of injury
Give details of how and precisely where the incident took place.
Describe what activity was taking place, for example training/game/getting changed.
Give full details of action taken during any first aid treatment and the name(s) of first-aider(s).
Were any of the following contacted?
Parents/carers Yes ( No (
Police Yes ( No (
Ambulance Yes ( No (
PTO
What happened to the injured person following the accident/incident?
E.g., carried on with session, went home, went to hospital etc.
All of the above facts are a true record of the accident/incident
Signed Date
Name
In the event of an accident occurring through insufficient training or faulty equipment/facilities, follow up action to include completion of risk assessment form.
Please leave completed form in a sealed envelope behind the clubhouse bar, marked FAO Bridget Petty, LAC Club Welfare Officer and notify by phone on 07710 369598 or e-mail bridget@jpsprint.co.uk.
Leeds Adel Carnegie Hockey Club
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2007-03-30T11:11:24+01:00
2007-03-30T11:11:24+01:00
2007-03-30T11:11:24+01:00
uuid:9AA31768DF3A11DB84DC81CDD610C956
uuid:9AA31769DF3A11DB84DC81CDD610C956
uuid:58A54320BFD611DBB109D617C09025DD
uuid:58A5431FBFD611DBB109D617C09025DD
3
sRGB IEC61966-2.1
1
3000000/10000
3000000/10000
2
256,257,258,259,262,274,277,284,530,531,282,283,296,301,318,319,529,532,306,270,271,272,305,315,33432;DF2298BB6AE8D19A48D34E3B7809BB54
118
68
1
36864,40960,40961,37121,37122,40962,40963,37510,40964,36867,36868,33434,33437,34850,34852,34855,34856,37377,37378,37379,37380,37381,37382,37383,37384,37385,37386,37396,41483,41484,41486,41487,41488,41492,41493,41495,41728,41729,41730,41985,41986,41987,41988,41989,41990,41991,41992,41993,41994,41995,41996,42016,0,2,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,20,22,23,24,25,26,27,28,30;E38F4F53215978050F0F47C0B1738E40
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