Workplace Incident Nurse Triage Assessment Form
Please complete this form to document and assess the details of the workplace incident for nurse triage.
Date and time of incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of incident
*
Type of incident
*
Slip, trip, or fall
Cut or laceration
Burn
Exposure to chemicals
Strain or sprain
Other
Brief description of incident
*
Symptom assessment
*
Rows
None
Mild
Moderate
Severe
Pain
1
2
3
4
Bleeding
5
6
7
8
Swelling
9
10
11
12
Loss of consciousness
13
14
15
16
Difficulty breathing
17
18
19
20
Rate the urgency of the situation
*
Not urgent
1
2
3
4
Extremely urgent
5
1 is Not urgent, 5 is Extremely urgent
Immediate actions taken
*
First aid provided
Emergency services called
Returned to work
Sent for further medical evaluation
Other
Nurse assessment and notes
*
Recommended next steps
*
Return to work
Monitor symptoms
Seek further medical evaluation
Other
Name of nurse completing this assessment
*
Submit Assessment
Should be Empty: