DETAILS OF INJURED PLAYER

Your Name: *

Injured Players Name: *

Your Role: *

Team: *

Your contact number: *

Your email Address *

Your address: *

Date of accident * +

Time of accident *

ENGLAND HOCKEY INJURY REPORTING

England Hockey require data of injuries sustained across the sport so that trends can be identified and reported to both England Hockey’s Board and the International Hockey Federation to ensure the safety and integrity of hockey and all those who participate in the sport.

England Hockey require clubs/associations to complete an ‘Injury Monitoring Form’ following injuries sustained that require one or more of the following:

- Treatment from a first aid specialist (e.g. Team doctor/ first responder)

- Hospital treatment

- Subsequent visit(s) to a GP

All clubs/associations have a responsibility to record injuries using accident report forms. All personal information will be processed, stored and retained in accordance with both the Club’s Privacy Notice and GDPR.

Non-Compliance with England Hockey’s Injury Reporting Policy England Hockey takes the safety of its members extremely seriously and for this reason, members’ commitment to Safe Hockey has been included as a condition of affiliation. In the event that a member club/associations fails to complete England Hockey’s ‘Injury Monitoring Form’ for any injury which meets the criteria outlined in England Hockey’s Injury Reporting Policy, or fails to comply with the terms of affiliation relating to Safe Hockey, England Hockey reserves the right to review the affiliation status of the club/associations in question and/or consider disciplinary action.

Where did the injury take place? *

Adult match

Junior match

Adult training

Junior training

Who was injured? *

Adult Player - male

Adult Player - female

Junior Player - male

Junior Player - female

Did the injury occur during a Penalty Corner or Open Play? *

Penalty Corner

Open Play

What was the injury caused by? If "Other", please specify *

Ball

Stick

Body

Other Other

Did the injury require hospital treatment? *

Yes

No

Which part of the body was affected? *

What type of injury was sustained? If "Other", please specify *

Concussion

Fracture / Break

Sprain / Strain / Ligament / Tendon

Bruising / Wound Bruising / Wound

What type of protective equipment was worn at the time of injury? Please select all that apply. If "Other", please specify *

Face Mask

Gum Shield

Shin Pads Shin Pads

Please provide us with some brief details of the injury *

0/500 characters

SAFEGUARDING REPORTING

Have the parents / carers been notified: *

Yes

No

Parent / Carers Name: *

If yes. what has been agreed *

0/500 characters

Has the incident been fully dealt with? *

Yes

No

Please explain how it has been fully dealt with? *

0/500 characters

Is any further action needed? *

Yes

No

If so, please describe any further action to be taken *

0/500 characters

Todays date: * +