On Field Injury Report Form - Hockey Western Australia

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This report is to be completed for all on-field injuries by players, officials & coaches as soon as possible after the incident for Hockey WA records.

If an insurance claim is required, please visit the Insurance page on Hockey WA's website.

Date of Injury*

Time of Injury*

Venue where incident occurred*

Details of Injured Person

Full Name*

Address*

Email Address*

Mobile Number*

Gender*

Male

Female

Other

Rather Not Say

Approximate Age*

Club*

Grade*

Category of injured person*

Type of Clothing*

Footwear*

Was the injured person wearing glasses, have walking aids, or were they carrying anything?*

Injured Persons Version of Events

Details of Incident*

Cause of Injury*

(i.e. Struck by ball, slipped over, collision etc.)

Injured Body Part*

Were the venue staff notified of the injury?*

Yes

No

Details of Witness

Witness Full Name*

Address*

Email Address*

Mobile Number*

Club*

Grade*

Does the witness agree with the Injured Person's description of the incident?*

If no, detail witness's version of events

Medical Details

Was First Aid required?*

What First Aid treatment was administered?*

(i.e. Ice applied, antiseptic used to clean wounds etc.)

Who administered First Aid?*

Did an ambulance attend?*

Yes

No

Was the Injured Person taken to hospital?*

Yes

No

Did the Injured Person have to leave the venue?*

Yes

No

Any other information

(i.e. Referred to a doctor, taken for X-Rays etc.)

Environmental Conditions

Weather*

Approximate Temperature*

Surface*

Wet

Dry

Was the lighting adequate?*

Yes

No

Crowd*

(approximate number at time of incident)

Form Completed By

Full Name*

Position*

(i.e Injured Person, Coach, Team Manager, Ground Controller etc.)

Email Address*

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Perth Hockey Stadium, Hayman Road, Bentley WA 6102
admin@hockeywa.org.au
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