Player assessment

Name of assessing staff member

Does the player give consent for assessment and treatment (if required)?*

YesNo

Does the player give consent for information taken to be stored and shared with relevant staff members at the University, as well as other relevant medical professionals, in-line with data protection guidelines?

YesNo

Name of player

Is the player a UOP student?

YesNo

Student number

Where are they from?

For example, club or university name, home or away team, external booking

Phone number

Email

Date of birth

What sport was being played?

Description of injury or illness

Type of injury or illness?

ConcussionInjuryMedically unwell (illness)No concussion

Assessment taken?

Injury assessed by sports injury teamInjury assessed by local first aid teamInjury assessed by UOP Staff memberNo assessment undertaken

Description of assessment taken

Treatment of injury

Advised on acute injury managementAdvised on concussion managementBasic first aid / wound managementNo treatment undertaken

Description of treatment provided

Player action taken

Working diagnosis

Safety netting

Advised to escalate to a medical professional in the event of any worsening signs or symptoms

Location

PortsmouthAway

Player assessment

The player

The incident

Where did the incident happen?