FW Touring Team – Injury, Incident & Illness Record Form FW Touring Team - Injury, Incident & Illness Record Form ***Add Description*** "*" indicates required fields Step 1 of 5 20% Details of person completing this recordName*Position / Role*Child detailsChild’s Full Name*Date of birth DD slash MM slash YYYY Age*Gender* Male Female Non-Binary / Gender Fluid Other Incident DetailsTour / Event Name*Incident date* DD slash MM slash YYYY Incident time* Hours : Minutes AM PM AM/PM Location*General activity at the time of incident*Incident type*Please select oneInjury / TraumaIllnessMissing childItem lost/stolen/damagedOtherCause of injury/traumaCircumstances surrounding any illness, including apparent symptomsCircumstances if child appeared to be missing or otherwise unaccounted forInclude duration, who found child, etc.Full details of when/where and how item was lost/damaged/stolenInclude who took the child and duration.Circumstances if otherNature of injury/traumaIndicate on diagram the part of body affectedTap/drag on the diagram to mark the affected area. Specify the injury:* Abrasion / Scrape Amputation Bite wound Bruise Broken bone / Fracture / Dislocation Burn / Sunburn Choking Concussion Crush / Jam Cut / Open wound Drowning (non-fatal) Electric shock Eye injury Ingestion / inhalation / Insertion Internal injury / Infection Poisoning Sprain / Swelling Stabbing / Piercing Tooth Venomous Bite/Sting Other If other (injury), please specify:*Nature of illnessSpecify the illness:* Allergic reaction (not anaphylaxis) Anaphylaxis Asthma / respiratory Infectious disease (incl gastrointestinal) High temperature Rash Respiratory Seizure / Unconscious/ Convulsion Other If other (illness), please specify:* Action TakenDetails of Action Taken:*including first aid, administration of medication etc.Did Emergency Services attend ?* Yes No If Emergency Services attended, please provide details:*Was medical attention sought from a registered practitioner / hospital?:* Yes No If medical attention was sought from a registered practitioner / hospital, please provide details:*Have any steps been taken to prevent or minimise this type of incident in the future?* Notifications (including attempted notifications)Parent / GuardianTime Hours : Minutes AM PM AM/PM Date DD slash MM slash YYYY Manager / CoordinatorTime Hours : Minutes AM PM AM/PM Date DD slash MM slash YYYY Regulatory authority (if applicable)Time Hours : Minutes AM PM AM/PM Date DD slash MM slash YYYY Any additional notes:Summary