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Data entered into this form will be used to help UFNSW maintain its duty of care to its members. This will be done both in the present time with follow up on particular incidents as necessary and on an historical basis for reviews of policy.

Please enter as many details as you can on the following form. None of the entries are mandatory but the more information you enter the better we will be able to manage the data.

Injured's AFDA #
Date    
Approximate Time :   (eg. 20:45 = 8:45pm)
Location   (eg. Gore Hill, UNSW Oval, Terrigal Beach)
League/Tournament   (eg. NSL, MUFL, Nationals, Pickup)
Injured's Surname   (Used to cross check AFDA#)
Injured's Team Name
Injury Type   If "other" describe 
Injury Cause If "other" describe 
How serious   (eg. 1=Continued play, 3=Retired from game, 5=Ambulance)
Treatment Type   (eg. ice pack, physio, specialist)
Claiming Insurance Important: If claiming AFDA insurance you must still complete the claim form and contact the AFDA Insurance Officer.

Please add any further information that you feel is relevant, or describe the incident in more detail.