First Aid Incident Report Form
Personal Details
Name of Person:
First Name
Last Name
Date of Birth:
/
Month
/
Day
Year
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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Information of First Aider
Name of First Aider:
First Name
Last Name
Job Title and Department:
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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:
*
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Should be Empty: