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The Physio Society

Equity Advisory

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CONCUSSION / INJURY REPORT

Details of Person Completing Form

Full Name*

Phone*

Email*

Club / Team*

Position / Role*

Details of Injured Person / Incident

Full Name*

Phone*

Email*

Age at the time of injury*

Date of incident*

Day

Month

Year

Location / Venue*

Activity at time of incident*

Match

Training

Cause of incident*

Ball

Stick

Body / Collision

Detailed description of the location on the body of the injury*

Detailed description of the injury / incident*

Action taken*

None

Removed from field

Refused to leave field

Assessed by onsite medical

Referral*

None

Medical Practitioner

Emergency room / department

Ambulance

Office Use Only

Date recorded: __________

Medical clearance required (Y/N): __________

Clearance advice / form received (Y/N, N/A): __________

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