Accident Report Form - Hockey Western Australia

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This report is to be completed for all off-field injuries 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 accident*

Time of accident*

Venue where accident occurred*

Details of Injured Person

Full Name*

Address*

Email Address*

Mobile Number*

Gender*

Male

Female

Other

Rather Not Say

Approximate Age*

Club*

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. slipped over, dropped hot drink on self, rolled ankle on hill etc.)

Injured Body Part*

Were the venue staff notified of the injury?*

Yes

No

Details of Witness

Full Name*

Address*

Email Address*

Mobile Number*

Club*

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, Team Manager, Supporter, Ground Controller etc.)

Email Address*

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Perth Hockey Stadium, Hayman Road, Bentley WA 6102
admin@hockeywa.org.au
+61 8 9351 4300

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