Incident/Injury Report Form

This form is used to log an accident/injury at a match/training event - its for internal use only and is not part of the Player Injury Fund Process

PLAYER INJURY CLAIMS MUST BE SUBMITTED SEPARATELY VIA THE CLUB SECRETARY

All necessary forms to submit a claim can be found here

Please download, complete & return to secretary.cuala.dublin.gaa.ie

Full Details of the Player Injury Fund here

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Date (Date of Incident):*

Location of Incident:*

Injured Person's Name*

Gender:*

Age:*

Contact Phone No:*

Description of Incident: (Activity involved, What happened)*

Describe Injury: (Part of body, Nature of injury)*

Action Taken: (Tick all that apply)*

None Required

Parent Called

First Aid required

Ambulance Required

Person in charge *

Position (Coach/Mentor)

Person in Charge Phone No:*

Surface condition:*

Names/contact details of others that assisted in any way: (Called ambulance, provided First Aid, called parents)*

Any additional comments relevant to incident: (if injury happened in a match, did referee record it in match report - refs name etc)

Report Completed by:*

Email*

ACCIDENT / INJURY REPORT FORM

PLAYER INJURY CLAIMS MUST BE SUBMITTED VIA THE CLUB SECRETARY WITHIN 60 DAYS OF THE INJURY

PLAYER INJURY CLAIMS MUST BE SUBMITTED SEPARATELY VIA THE CLUB SECRETARY