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:
Blisters
Blood Nose
Burn
Cardiac problem
Cut
Electrical Shock
Fracture / Break
Heavy Bleeding
Infection
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
2
3
4
5
After spoken or shouted request
6
7
8
9
After finger tip stimulus
10
11
12
13
No opening at any time, no interfering factor
14
15
16
17
Closed by local factor
18
19
20
21
Verbal Response:
Rows
Orientated
Confused
Words
Sounds
None
Non testable
Correctly gives name, place and date
22
23
24
25
26
27
Not orientated but communication coherently
28
29
30
31
32
33
Intelligible single words
34
35
36
37
38
39
Only moans / groans
40
41
42
43
44
45
No audible response, no interfering factor
46
47
48
49
50
51
Factor interfering with communication
52
53
54
55
56
57
Best Motor Response:
Rows
Obeys commands
Localising
Normal flexion
Abnormal flexion
Extension
None
Non testable
Obey 2-part request
58
59
60
61
62
63
64
Bends arm at elbow
65
66
67
68
69
70
71
Extends arm at below
72
73
74
75
76
77
78
No movement in arms / legs
79
80
81
82
83
84
85
Paralysed or other limiting factor
86
87
88
89
90
91
92
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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: