Workplace First Aid Incident Report Form
Complete this form to document all relevant details of a workplace first aid incident, including what happened, who was involved, treatment given, and follow-up.
Date and time of incident
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of incident
*
Name of person(s) involved
*
Role of person(s) involved
*
Please Select
Employee
Contractor
Visitor
Other
Describe what happened
*
Nature of injury or illness
*
Cut/Laceration
Burn
Sprain/Strain
Fracture
Bite/Sting
Eye injury
Fainting/Collapse
Other
First aid treatment provided
*
Bandaging
Ice pack
Cleaning wound
CPR
Recovery position
Assisted to rest area
Other
Name of person administering first aid
*
Were there any witnesses?
*
Yes
No
Follow-up actions required or taken
*
Returned to work
Sent home
Referred to medical professional
Monitoring required
Other
Submit Report
Should be Empty: