Accident Report Form

This form is to be completed and submitted immediately following any accident from which an investigation may follow

Your Name *

First

Last

Where you the volunteer in charge of the activity *

• Yes
• No

name accident taken

If you answered No, who was in charge

Team name & age group accident relates to *

Your role or relationship to RSFC: *

Your contact number *

Email *

Name of person or persons injured *

Location of accident *

Date of accident DD/MM/YYYY *

Time of accident *

At what Runcorn Saxons FC activity did the accident happen during *

• League or Cup Match
• Team Training
• Other

You can check more than one option

If you selected 'Other' please give details

Nature of accident i.e. Head Injury *

Give details of how and precisely where the accident took place *

Give details of the action taken including any first aid treatment and the name(s) of the first-aider(s). *

Were any of the following contacted

• Ambulance
• Parent / Guardian

You can check more than one option

If the accident was a Head Injury did you share a Head Injury Card or tell the parent / guardian to review the Clubs Head Injury Card on the Downloads page of our website *

• Yes
• No
• It wasn't a Head Injury

What happened to the injured person after the accident? (eg. went home, went to hospital, carried on with game or session) *

By selecting YES and submitting this form you are confirming the above facts are a true and accurate record of the accident and the action taken *

• YES

Submit

Once submitted this form will be sent to the Club Secretary for review.

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