First Aid Report Form
A First aid report form is used to provide information of an injury/accident happened at any workplace in which an employee was affected and given the first aid treatment. This report form is usually prepared by work security officer to keep a record of injuries at workplace and to make arrangement for compensation if necessary.
Sample First-aid Report Form
General Information
Name of Workplace____________ Title of Project____________
Address_____________ Phone____________ Email_________
Supervisor Name_________ Phone___________
First-Aid Report Information
Date of incident, when first aid was given___/___/____ Time/Hours________
Place________
Name of Person given the first-aid___________ Age_______ Sex________
Designation_____________
Address__________ Phone___________
Causes of injury__________
The activities of person at the time of injury___________
First witnesses of injury and first-aid________________
Brief description of circumstances in which first aid was given__________________
Nature of injury: Serious/Non Serious______________
First –aid given for: Describe the injury/suffering________________
Any medical treatment provided to affected person after first-aid_________
Name the Hospital/Physician_____________ Address_________ Phone__________
Extra Remarks_______________
Signature_____________ Date of Report Submission____/___/____
Category: Report Forms
