Medical incident Report Form
Incident report number
Patient Details
Name of 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
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
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 the Incident:
Does patient require EMS transport?
*
Yes
No
Reported or visible symptoms of Injury:
Pick 1 or more:
Blisters
Blood Nose
Burn
Cardiac problem
Cut
Electrical Shock
Fracture / Break
Heavy Bleeding
Infection
Pick 1 or more:
Loss of consciousness
Open wound
Poisoning
Strain
Graze
Pain
Tenderness
Insect Bite
Other
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Glasgow Coma Scale:
Eye Opening:
Rows
Spontaneous(3)
To sound(2)
None(1)
None testable
#
Verbal Response:
Rows
Orientated(4)
Confused(3)
Words(2)
Sounds(1)
None(0)
Non testable
#
Best Motor Response:
Rows
Obeys commands(5)
Localising(4)
Normal flexion(3)
Abnormal flexion(2)
Extension(1)
None(0)
Non testable
#
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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
Submit
Should be Empty: