Injury Report Form
Injury reports are to be emailed to [email protected] within 48 hours of
the injury coming to the notice of the referee or team management.
Athlete Information
Name of Athlete:
DOB:
Playing Position:
Game 
Team:
Training 
Sex:  M  F
Grade:
Conditions:
NZRU ID No:
Date of Injury:
Venue Played/Surface Type:
Injury Information
Injured Side:  R  L
Injured Region:
 Abdomen
 Ankle
 Back
 Chest
 Elbow
 Face/Eyes
Nature of Injury:  Acute  Chronic  Re-injury
 Fingers/Hand
 Foot/Toes
 Forearm
 Groin/Pelvis
 Hip
 Head
 Knee
 Lower Leg
 Neck
 Fracture
 Laceration
 Collapsed Maul
 Ruck
 Post Tackle
 Kicking
 Shoulder
 Thumb
 Trunk/Chest
 Upper Arm
 Upper Leg
 Wrist
Specific Region:
Suspected Injury:
 Concussion
 Dental
 Dislocation
 Sprain/Strain
 Other (specify):
Event Causing Accident:
 Scrum Engagement  Collapsed Scrum
 Lineout
 Maul
 Other (specify):
Tackle (specify)
Tackler
Ball Carrier
Athlete Status
 Continued to play
 Running
Was foul play involved?  Yes
 Front
 Front
 Side
 Side
 out 1+ days
(specify):
On-field Treatment Provider
 Doctor
 Referee
 St Johns
 Other (specify)
 Team Official
 Behind
 Behind
How many players were involved in the tackle?
 1  2  More
 out 1+ weeks
(specify):
Method of Leaving the Field
 Ambulance
 Stretcher
 Out for season
 Other (specify)
Brief description of how the Injury occurred:
Designation (Manager, Coach etc):
Name of Report Filler:
Contact No:
Club:
 No
Signature: