First Aid Incident Report Form
Personal Details
Name of Injured Person:
First Name
Last Name
Date of Birth:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Gender:
Female
Male
Contact Details
Phone Number:
-
Area Code
Phone Number
Email
example@example.com
Address:
Street Address
Street Address Line 2
City
Province
Postal Code
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Details of Incident
Date and Time of Injury:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
2 digit month, 2 digit day, 4 digit 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/Describe the Incident:
Please Specify the Location of Incident:
Does Injury require EMS?
Yes
No
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Information of First Aider
Name of First Aider:
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
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Treatment/Recommendations/Outcome
Please give details about the Treatment:
Please give details about the Recommendations
Go to Hospital, See Family Doctor, sit and come back when ready
Please give details about the Outcome
Returned to training, said they would go to hospital/doctor
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Report Prepared By & Signature
Report Prepared By:
First Name
Last Name
Signature:
*
Submit
Should be Empty: