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NSW Football Legacy Program

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Home / Program Injury Report Form

Program Injury Report Form

"*" indicates required fields

Date of Incident*

DD slash MM slash YYYY

Time of Incident*

Hours

:

Minutes

Location or address where injury occurred*

Name of event or activity (if applicable)

Type of injury*

Cut, abrasion, allergy, bruising, soft tissue

Sprain, strain, muscle injury

Fracture

Eye injury

Back injury

Head injury

Environmental injury (e.g. air pollution, smoke, chemical)

Other type of injury

Please specify other*

Location of injury on body:*

Type of treatment*

First aid

Medical (GP or emergency department)

Physiotherapy

Ambulance

Hospital

Counselling

Other

Please specify other*

Name of injured FNSW Employee*

First Last

Role at time of injury*

Department*

Contact Phone No.*

Contact Email Address*

Personnel Type*

Player

Coach

Manager

Referee

Volunteer

Ground Official

Spectator

Other

Please specify other*

Gender*

Female

Male

Name of Guardian/Next of Kin*

First Last

Relationship*

Contact number*

Contact email*

Name of person reporting the incident*

First Last

Role of person reporting the incident*

Contact phone number*

When was incident reported?*

DD slash MM slash YYYY

Time it was reported*

Hours

:

Minutes

Name of Witness

First Last

Witness contact number

Description of how injury/incident occurred*

Does the cause of the injury need to be referred to WHS committee or VSP manager to reduce the risk from causing injury to another person?*

Yes

No

Photos/Medical Reports/Other reports

Max. file size: 15 MB.

02 8814 4400 reception@footballnsw.com.au Mon - Fri, 9am - 5pm

Valentine Sports Park
235 - 257 Meurants Lane
Glenwood NSW 2768

PO Box 6146
Baulkham Hills BC NSW 2153

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