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Consent obtained*
I give or have obtained consent for the storage of these injury records.
Your contact details
Full name*
Contact number*
Email address*
Basic information
Injured person
Name*
Phone number*
Email*
Age at the time of injury*
Please select...
Unknown
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Details
Date*
Time*
Venue*
Please select...
Cornelian Bay
Hockey Tasmania
How did the injury occur*
Please select...
Collision with fixed object
Collision with other person
Fall/stumble
Jumping
Landing from jump
Overexertion
Overuse
Slip/trip
Struck by ball (e.g. dislocated finger)
Struck by other player
Struck by playing equipment
Temperature-related (e.g. heat stress)
Twisting to pass or accelerate
Other
Description*
Additional information
Injury details
Type of injury*
Please select...
Abrasion/graze
Bruise/contusion
Cardiac problem
Concussion/suspected concussion
Dislocation/sublaxation
Fracture/suspected fracture
Inflammation/swelling
Open wound/laceration/cut
Sprain (e.g.
ligament)
Strain (e.g.
muscle
tendon)
Respitory problem
Unspecified medical condition
Other
Body part injured?*
Please select...
Back
Cheek
Chest
Ear
Eye
Forehead
Head
Mouth/Teeth
Neck
Nose
Other
Unknown
Protective gear worn*
Face mask
Gloves
Helmet
Mouthguard
None
Knee pads
Other
Shin pads
Unknown
Other injury details*
Max. 255 characters
Type of activity when injured*
Please select...
Training
Match
Match activity when injured
Please select...
Penalty Corner
Normal game play
Shoot Out
Hockey action when injured
Please select...
Dragflick
Overhead
Slap hit
Tackle
Tomahawk
Other
Action & Referral
Immediate action taken
Please select...
Assessed by onsite medical
Refused to leave field
Removed from field
None
Referral action taken
Please select...
Ambulance
Emergency room/department
None
Unknown
Concussion details
Has the injured person sustained multiple concussion injuries?
Please select...
Yes
No
Was there loss of consciousness?
Please select...
Yes
No
Reporter's Details
Your role in hockey*
Please select...
Athlete
Coach
Administrator
Official/Upmire
Support Personnel (e.g. team manager/SSSM personnel)
Parent/carer
Spectator
Other
Injured Person's Details
Injured person's club/team*
Injured person's Member Association*
Please select...
Hockey ACT
Hockey NSW
Hockey NT
Hockey Queensland
Hockey SA
Hockey Tasmania
Hockey Victoria
Hockey WA
Unknown
Medical Clearance
Is a medical clearance required?
Please select...
Yes
No
Medical clearance documentation
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Launceston
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