SA Rugby - Official Home of the Springboks

Blue Card Incident

What happened?

Date that concussive injury occurred? *

Estimated time of the concussive injury? *

(Please enter in 24 hours time format eg: 17:15)

Venue where concussive injury occurred? * (Please enter the venue/school or field name)

Event that caused the concussive injury? *

Injured player's Club/School TEAM? *

Opposing Club/School TEAM?*

Provincial Rugby Union where concussive injury occurred? *

Tell us who you are

Tell us who you are ?

Your designation/role?

Your Name ?

Your Surname?

Your email address?

Whats is your mobile number?

Who was involved

Who was involved1

Name of the player?

Surname of the player?

Email address of the player?

Mobile number of the player?

ID / Passport / Date of Birth of the player

Age

School / Club Name

Town / City

Province

Player position at time of incident?

Gender of the player?

Ethnicity of the player?

Add Additional contacts

Click on the ADD button to add a contact or more contacts to include in the communication for this incident report. You will be limited to a maximum of 4 contacts.

Designation/Role?

Name & surname of contact?

Email address of contact?

Consent

SA Rugby Injury and Illness Surveillance and Prevention Project (SARIISPP)

BLUE CARD HEAD/CONCUSSION INJURY DATA FOR SARIISPP

I hereby provide informed consent to the use, processing and storage of the personal information provided herein and that the captured Blue Card head/concussion injury information, may be used by SA Rugby and their nominated research partners for injury record and research purposes.

By continuing with the process of logging or documenting this event, I provide informed consent to SA Rugby and their nominated research partners, to access all relevant information pertaining to the rugby-related Blue Card head/concussion injury.

I furthermore agree to release to SA Rugby, all Blue Card head/concussion injury data sustained during any SA Rugby associated leagues or tournaments, which may include, but are not limited to Currie Cup, and any other amateur community rugby matches and training associated with SA Rugby, the local Provincial Rugby Union, Club or School affiliated rugby activities.

The Blue Card head/concussion injury data, as stipulated above, may or may not be used for research purposes. This information will be stored at SA Rugby’s offices for official records of these rugby-related injuries.

The Blue Card head/concussion injury data may be used for research and publication purposes to help improve the safety standards of the game of rugby played in South Africa, and can be used to potentially prevent other similar injuries from occurring in the future.

I further understand and acknowledge that all analysed, researched or published information, will be depersonalized, will remain anonymous, and will be treated and handled with the utmost confidentiality.