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Rutherford College Incident/Accident Reporting Form (2018)

This form is to be completed for Incidents/ Accidents of concern relating to a Sports Injury. To the best of your ability please describe in detail how the Accident/ Injury occured. 

Please do not reply to this email. It is sent automatically to acknowledge that a form has been completed with Rutherford College with details below.

First Name
Last Name
Phone 1:
Name of injured person
Date of Birth
Phone Number
Type of Injury
Date of Accident
Time of Accident
Describe what happened
0 /
Describe what caused the accident/incident
0 /
How serious couId it have been:
How often is it likely to happen again:
Witness (include contact details)
0 /
Description of actions taken at the time of incident/accident (include medical treatment):
0 /
Property/Equipment/Material Damage:
Nature of Damage
Cause of Damage

By you submitting your information, you agree to us releasing your contact information and all information submitted by you to a third party if necessary, and you further agree and understand that you may be contacted directly  if this incident needs to be investigated or additional information is required.