First Aid Incident Report Form
Personal Details
Name of Person:
First Name
Last Name
Date of Birth:
/
Month
/
Day
Year
1
Gender:
Female
Male
Contact Details
Phone Number:
-
Area Code
Phone Number
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Details of Incident
Date and Time of Injury:
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Date and Time of Arrival at First Aid:
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Please Specify the Incident:
Does Injury require Hospital / Physician?
Yes
No
Reported or visible symptoms of Injury:
2
Blisters
Blood Nose
Burn
Cardiac problem
Cut
Electrical Shock
Fracture / Break
Heavy Bleeding
Infection
3
Loss of consciousness
Open wound
Poisoning
Strain
Graze
Pain
Tenderness
Insect Bite
Other
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Glasgow Coma Scale:
Eye Opening:
Rows
Spontaneous
To sound
None
None testable
Open before stimulus
4
5
6
7
After spoken or shouted request
8
9
10
11
After finger tip stimulus
12
13
14
15
No opening at any time, no interfering factor
16
17
18
19
Closed by local factor
20
21
22
23
Verbal Response:
Rows
Orientated
Confused
Words
Sounds
None
Non testable
Correctly gives name, place and date
24
25
26
27
28
29
Not orientated but communication coherently
30
31
32
33
34
35
Intelligible single words
36
37
38
39
40
41
Only moans / groans
42
43
44
45
46
47
No audible response, no interfering factor
48
49
50
51
52
53
Factor interfering with communication
54
55
56
57
58
59
Best Motor Response:
Rows
Obeys commands
Localising
Normal flexion
Abnormal flexion
Extension
None
Non testable
Obey 2-part request
60
61
62
63
64
65
66
Bends arm at elbow
67
68
69
70
71
72
73
Extends arm at below
74
75
76
77
78
79
80
No movement in arms / legs
81
82
83
84
85
86
87
Paralysed or other limiting factor
88
89
90
91
92
93
94
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Information of First Aider
Name of First Aider:
First Name
Last Name
Job Title and Department:
Employee ID:
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Treatment
Please give details about the treatment:
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Report Prepared By & Signature
Report Prepared By:
First Name
Last Name
Signature:
*
Submit
Should be Empty: