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Injury/Incident Form
Report an injury or incident below. Please ensure all information is accurate as this may be used for insurance purposes. An injury report is not an insurance claim. To make a claim, please visit the
insurance page
. Have a question?
Contact Us
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Reporting an injury/incident
For myself
On behalf of someone else
Name
*
First
Last
Phone
*
Email
*
Name of injured person?
Name (injured)
*
First
Last
Phone (included)
Email (copy)
*
Team playing for?
Team playing against?
Location
Location
Carseldine
Forest Lake
Toowong
Wynnum
Other
Please specify
Date of injury / incident?
Time of injury / incident?
Type of injury / incident?
How did the injury / incident occur?
First aid or treatment given?
Outcome
Outcome
Ambulance called
No first aid required
Left location under own's power
Taken to hospital by friend or family member
Incident prevention feedback
Signature
*
Clear Signature
Submit
