Accident Form - Instonians Rugby Belfast

Players Name*

Date of Birth or Age of Player

Club / School Name*

Contact name for IRFU follow up if required*

Contact number for IRFU follow up if required*

Person Completing Form Name*

Role in Club / School

Contact Number

Date Form Completed

Date Of Injury

Event at time of injury

Team Type ( E.g Mini, Senior)

Mechanism of Injury

Did the referee indicate that the action leading to the injury was a violation of the Laws?*

Body Part Injured

Type of injury

If You Select Other Please Specify

What Treatment was Administered To The Player At the Time Of the Injury?

Did the player require a hospital attendance (i.e. attend hospital but not admitted overnight)*

Did the player require a hospital admission (i.e. admitted to hospital for one or more nights)

If the player is underage, was a parent/guardian informed?

Additional Comments