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Injury Report Form
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Staff Name
*
First
Last
Staff phone number
*
Incident Date and Time
*
Date
Time
Injured Person
*
First
Last
Details of the incident
*
Injury type / description
Treatment/management
Hospital/Physician required?
*
Yes
No
Details
Other notes/information
Staff Signature
Clear Signature
Date / Time
Date
Time
Participant Signature
Clear Signature
Date / Time
Date
Time
Name
Submit
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