ACCIDENT REPORT FORM/ FORMULAIRE de

ACCIDENT REPORT FORM/ FORMULAIRE de RAPPORT d’ACCIDENT
OFF ROAD GROUND POST/ POSTE de SECOURS EN TOUT TERRAIN
EVENT/ EPREUVE:
DATE:
MEDICAL OFFICER/ RESPONSIBLE MEDICAL:
VENUE/LIEU:
Date
Time
Heure
Starting no of rider
No depart coureur
Official or spectator
Official ou spectateur
Post no or Location
No du poste ou lieu
Name, nationality and address/ Nom,
nationalite et adresse
Age
Injury
Blessure
Note: The form must be filled in by either typing or in a neat hand writing using a ball point and emailed back to the medical commission.
Mode of
transport
Referral hospital
Hopital d’accueil