Foreign Object Injury Assessment Form
Document and evaluate incidents involving a foreign object injury using this comprehensive assessment form.
Incident Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident Time
*
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Injured Person's Full Name
*
First Name
Last Name
Contact Information (Phone or Email)
*
Describe the Injury/Incident
*
Body Part Affected
*
Please Select
Eye
Hand
Foot
Arm
Leg
Head
Torso
Other
Type of Foreign Object Involved
*
Please Select
Metal
Wood
Glass
Plastic
Stone
Organic material
Other
Was the Object Removed?
*
Yes, by the injured person
Yes, by another person
No, still present
Current Symptoms or Condition (check all that apply)
*
Bleeding
Swelling
Pain
Numbness
Reduced movement
Redness
Other
Immediate First Aid or Actions Taken
*
Submit Assessment
Should be Empty: