Incident Notification Form printable pdf download

INCIDENT NOTIFICATION FORM

(COMPETITIONS ONLY)

Details

Competition:________________________________________ Venue:_______________________

Senior Referee:____________________________________________________________________

Tournament Director:________________________________________ Date:_________________

Incident/Accident

Injured Person Name:_______________________________________________________________

Club:_________________________________________ Grade:_____________ Weight:________

Opponent Name:__________________________________________________________________

Club:_________________________________________ Grade:_____________ Weight:________

Witnesses

Referee and Judges:_________________________________________________________________

Senior Recorder:__________________________________________________________________

Description of what occurred including any allegation of Professional Negligence:___________________

_______________________________________________________________________________

Medical

Was First Aid Administered on site?:

Yes

State if sent to Hospital:

Yes

Brief Description of Injury:___________________________________________________________

_______________________________________________________________________________

Attach Accident Report (if available)

Officials Signatures

I confirm the above information is to the best of my knowledge is accurate.

Tournament Director Signature:_______________________________________________________

Senior Referee Signature:____________________________________________________________

Injuries to be recorded on this form must include:

 Any fracture of suspected fracture (other than to toes, fingers, thumbs)

 Any head injury

 Dislocation or suspected dislocation of the shoulder, hip, knee, spine

 Unconsciousness

 Injury involving either referral to or actual hospital treatment



Any other serious injury that in the opinion of the club ought to be reported. This is particularly relevant where

minors are involved

Completed form should be sent to:

British Judo Association, Suite B, Loughborough Technology Centre, Epinal Way, Loughborough LE11 3GE

British Judo Association • Suite B • Technology Centre • Epinal Way • Loughborough • LE11 3GE

Tel: 01509 631670 • Fax: 01509 631680 • Web:

Incident Notification Form