UEFA

Information

This form is used to capture incident, clinical and personal information about patients presenting UEFA Europa League

Once a report has been submitted, it cannot be edited or amended further.

Please enter as much detail as possible, please be careful to select the options that best describe your patient.

Incident Details

Event Name: *

Location in Event *

Onset Date / Time *

Nature *

Outside Agencies Involved

Garda

Fire Brigade

HSE Ambulance

Security

Other

Patient Details

Patient Full Name: *

Patient Address

Please get Patient's Full Address and Post Code

Date of Birth *

Gender *

Patient Demographic *

Patient Identifier

Race Number, Bib Number, etc

Patient Phone Number

Next Of Kin Details:

Name/Telephone/Relationship to Patient

GP Practice Name, Address

Primary Survey

Primary Survey Done?

Yes

No

Patient Status

Calm

Un-Cooperative

Anxious

Abuse

Violent

Drug/Alcohol Suspected

Patient Assessment

Chief Complaint *

On Arrival *

Impression / Treatment *

Additional Information *

Image Upload

Drag and drop files here or Browse

Images relating to the accident, illness, scene or mechanism, ECG

Disposal *

Patient Signature *

If the Patient Refused Treatment/Transport

Medic Details

Medic Name: *

Medic Grade *

Medic PIN

Safe Guarding Referral *

Flag for Clinical Audit & Review *

Signature *

Incident Details

Patient Details

Primary Survey

Patient Assessment

Medic Details

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