Minor Injury Report Form for GC Medical and Security
Complete this form to document injury details, assessment, treatment, and outcomes for minor incidents.
Basic Details
Date of Incident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Job Type
*
Attendant Details
Attendant Name
*
Patient Details
Patient Full Name
*
First Name
Last Name
Patient Age
*
Patient Gender
*
Male
Female
Other
Injury Details
Type of Injury
*
Cut
Bruise
Sprain
Other
How did the injury occur?
*
Assessment
Brief Observations
Pain Level (0 = no pain, 10 = worst pain)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Is there bleeding?
*
Yes
No
Is mobility affected?
*
Yes
No
Treatment Provided
Treatment Provided
*
Wound care
Dressing
Ice
Advice given
Other
Outcome
Outcome
*
Returned to activity
Advised rest
Referred to GP
Escalated to ambulance
Consent obtained?
*
Yes
No
Additional Notes
Submit Report
Should be Empty: