Nzru Serious Injury Report Form - Bay Of Plenty Rugby
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2SERIOUS INJURY REPORT FORM
TEAM MANAGEMENT REPORT/REFEREE REPORT
Serious injury reports must be forwarded to the Provincial Union headquarters within 48 hours of the injury coming to the notice of the referee
or team management (see below for fax numbers for Provincial Unions)
Serious injury reports must be completed for the following injuries:
Any head or neck injury that requires the player to be transported directly from the ground to an emergency department, hospital or after hours medical centre
Any injury that results in the admission of a player into hospital after a game
Any injury that is expected to prevent a player from playing for a period of 8 weeks or longer
INJURED PERSON
Surname:
___________________________First Name(s):___________________________ Player Registration Number : _____________________________
Date of Birth:
/
/
Male / Female
Playing Position:
Grade:_____________________________
Date:
/
/
Time: _____:_____ am/pm
Place:
_________________
The injury occurred during: Match or Training
(please circle one)
Type of Injury
Site of Injury
Event Causing Injury
Concussion
Head
Scrum Engagement
Collapsed Scrum
Fracture
Neck
Lineout
Maul
Dislocation
Shoulder
Ruck
Collapsed Maul
Serious Joint
Back
Tackle (specify)
How many players were involved in the tackle?
Tackler
Front
Other (specify)
Arm
Tacklers
1
Side
Chest/Trunk
2
Behind
Thigh/Hamstring
On-field Treatment Provider
More
Ball Carrier
Front
Doctor
Knee
Side
St Johns
Lower leg
Was Foul Play involved?
Yes
No
Behind
Team Official
Other (specify)
Post Tackle
(please circle one)
(pre-ruck)
Referee Only
Kicking
Other (specify)
Running
Other (specify)
Method of Leaving the Field
Brief description of how the injury occurred:-
Ambulance
Stretcher
Other (specify)
Signed
Designation (e.g. Referee, Team Manager etc.) __________________________________
Contact No(s) Wk _____________________
Home ______________________________Mobile ______________________________
Provincial Union: _____________________________________
Club/School ___________________________________________
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