First Aid Risk Assessment Form
Personal Details
Name of Person Conducting the Assessment
Mr.
Mrs.
Prefix
First Name
Last Name
School/Workplace
Department
Additional Notes
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Items to be Considered for Provision of First Aid in the Workplace
1. Potential illnesses or life-threatening injuries and likely causes:
2. Type of work performed and the nature of the hazards:
3. The size and layout of the workplace:
4. The location of the site:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Are the following minimum First Aid Room requirements available?
Please fill the table below.
Rows
YES
NO
Eye Protection
1
2
Disposable Gloves
3
4
Gown/Apron
5
6
Resuscitation Mask
7
8
An Upright Chair
9
10
Sink (Hot & Cold Water)
11
12
Storage Cupboards
13
14
Sharps Disposal System
15
16
Desk, Table and Telephone
17
18
Electric Power Points
19
20
List of Emergency Numbers
21
22
Biohazard Waste Container
23
24
Work Bench or Dressing Trolley
25
26
Blankets and Pillows
27
28
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Minimum First Aid Facilities
Site Characteristics
Less than 50 employees (and students)
50 - 199 employees (and students)
200 - 399 employees (and students)
400 - 599 employees (and students)
600 - 799 employees (and students)
800 - 999 employees (and students)
>1000 employees (and students)
Where access is limited to medical and ambulance services (e.g. remote workplaces, school field excursions etc.)
Other
1 first aid officer - 1 first aid kit
*
Yes
No
N/A
2 first aid officers - 4 first aid kits
*
Yes
No
N/A
4 first aid officers - 6 first aid kits
*
Yes
No
N/A
6 first aid officers - 8 first aid kits
*
Yes
No
N/A
8 first aid officers - 10 first aid kits and a first aid room with a bed and stretcher
*
Yes
No
N/A
10 first aid officers - 12 first aid kits (including specific “type of incident” treatment) and a first aid room with a bed and stretcher
*
Yes
No
N/A
10+ first aid officer for every additional 100 employees and students - 12+ kits for every additional 100 employees and students - a first aid room with a bed and stretcher
*
Yes
No
N/A
2 additional first aid officers for every category - 2 additional first aid kits for every category
*
Yes
No
N/A
Please Explain the Site Characteristics.
*
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Review Controls
Workplace Manager and/or Management OHS Nominee verifies provision of the above first aid facilities:
*
Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: