First Aid Incident Form
Employee Information:
Name:
First Name
Last Name
Sex:
Please Select
Male
Female
Email:
example@example.com
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Work Phone:
Department:
Job Title:
Employment Type
Please Select
Full-time
Part-time
Other
Other:
INCIDENT INFORMATION:
Date of Incident:
-
Month
-
Day
Year
Date
Time of Incident:
Hour Minutes
AM
PM
AM/PM Option
Weather Conditions:
Wind Speed and Direction:
Temperature:
Were there pictures taken?
Please Select
Yes
No
Was there Evidence gathered?
Please Select
Yes
No
Was a sketch made of the accident?
Please Select
Yes
No
Other contributing factors to the incident:
Location of incident:
State all parts of body and type of injuries involved(e.g. bruised right elbow):
Describe how incident occured:
Was incident reported?
Please Select
Yes
No
To Whom:
Date Reported:
-
Month
-
Day
Year
Date
Were there witnesses?
Please Select
Yes
No
Unknown
Name of Witness #1 (First and Last):
Witnesses #1 Phone:
Name of Witness #2 (First and Last):
Witnesses #2 Phone:
Name of Witness #3 (First and Last):
Witnesses #3 Phone:
Name of Witness #4 (First and Last):
Witnesses #4 Phone:
Name of Witness #5 (First and Last):
Witnesses #5 Phone:
Additional Witnesses (Include Name and Phone):
Is this a new injury?
Please Select
Yes
No
Date of Original injury:
-
Month
-
Day
Year
Date
Was there blood involved in the incident?
Please Select
Yes
No
Do you think anyone may have had a bloodborne exposure
Please Select
Yes
No
INITIAL MEDICAL TREATMENT:
Was treatment received for this injury?
Please Select
No medical treatment - reporting only
Declining treatment at this time
Treatment was/will be provided
Treatment was provided by:
Please Select
Self
Occupational Health
Emergency Room
Other
NAME AND LOCATION OF MEDICAL PROVIDER:
Name:
Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Address:
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