North Canterbury Rugby

DETAILS OF INJURED PERSON

First Name

Last Name

AGE

DATE OF ACCIDENT

TYPE OF INJURY

INJURED PART OF BODY

Phone 1 (Mobile/Main)

Street Address

Suburb

Town/City

Postcode

DETAILS OF ACCIDENT

Date

TIME

LOCATION

THE ACCIDENT

DESCRIBE WHAT HAPPENED?

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WHAT WERE THE CAUSES OF THE ACCIDENT?

HOW BAD COULD IF HAVE BEEN?

WHAT IS THE CHANCE OF IT HAPPENING AGAIN? WHAT IS THE CHANCE OF IT HAPPENING AGAIN? *

WHAT HAS OR WILL BE DONE TO PREVENT IT HAPPENING AGAIN IN FUTURE? WHAT HAS OR WILL BE DONE TO PREVENT IT HAPPENING AGAIN IN FUTURE?

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TREATMENT GIVEN

TYPE OF TREATMENT GIVEN:

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NAME OF FIRST AIDER

INJURED PERSON VISITED

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