Polocrosse Association of NSW Incorporated eNewsletter

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Polocrosse Association of NSW Incorporated

SEO

Phone: 0407 207 649

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Accident Incident Report

Accident/Incident Report Form

This form combined with the Horse Vet Out form is to be utilised by Zone Umpires to collate information from carnivals regarding player and horse incidents. This form will cover any accidents involving horse or player and those incidents that may require a player to be sent off. A form must be submitted for each Accident/Incident.

Submission of this form will send notification directly to the State Chief Umpire and the SEO for record keeping.

If you have any questions about using this form please contact the State Chief Umpire stateumpire@nswpolocrosse.com.au or the SEO seo@nswpolocrosse.com.au

First Name *

Last Name *

Zone *

Host Club *

Event Location *

Was a player umpire meeting held prior to the start of the tournament? *

Yes

Weather Conditions *

Fine and Dry

Light Showers

Heavy Rain

Field Conditions

	Dry and Fine	Firm	Soft	hard
Grassed
Turf
No Grass

Were there any accidents? *

Yes - complete the rest of the form

No - submit your form now

Accident/Incident Date

Please name Match Umpire 1:

Please name Match Umpire 2:

Player Name

Did the player require first aid ?

Yes

Was the player concussed? *

Yes

Was the player able to finish the game?

Yes

Please give a brief description of the accident/incident

Upload the scoresheet and accident report

Were any horse/s injured?

Yes

Horse Name/Rider

Has the Horse Vet Out form been submitted?

Yes

Any other comments?