First Aid Incident Report

First Aid Incident Report
Date of incident
DayMonthYear
Date
Time of incident
:HourMinutesAM/PM Option
Name of person completing this report
First NameLast Name
Position
Phone Number
Area CodePhone Number
Email
example@example.com
Complete the following details about the person receiving first aid and the incident:
Name of person receiving first aid
First NameLast Name
FemaleMaleUnspecified
Age / Date of birth (if available)
Contact details of person receiving first aid (phone, email, address)
Where did the incident occur (clinic, school, preschool etc)
Cause of incident (if known)
Activities of the person at the time of incident / Events leading up to incident
Name and contact details of person(s) witnessing incident
Nature of the injury
Time first aid provided
:HourMinutesAM/PM Option
Description of first aid provided
Medical follow-up sought (if applicable)
Indicate below the area of the injury
Further information
Signature of first aid provider
Date
DayMonthYear
Date
Should be Empty: