First Aid Incident Report Form
First Aid Incident Report Form
Please fill out this form to document the first aid treatment provided.
Incident Information
Date and Time of Incident
Location of Incident
Incident Description
Incident Timeline
Detail the events leading up to the incident.
Cause of Incident (if known)
Injured Person Information
Name
Age
Gender
-
Male
-
Female
-
Phone number
Address
First Aid Responder Information
Name
Position
Phone number
First Aid Information
Injury Type
If other, please specify:
Body Part(s) Injured
Select all that apply:
-
Hand
-
Arm
-
Leg
-
Foot
-
Head
-
Torso
-
Type(s) of First Aid Provided
Select all that apply:
-
Bandaging
-
Cold Compress
-
Wound Cleaning
-
Splinting
-
CPR
-
Time Provided
Was further medical attention required?
Was the injured person taken to a hospital?
Witness Information
|
No. |
Name |
Contact Information |
|---|---|---|
|
1 |
|
|
|
2 |
|
|
|
3 |
|
|
|
4 |
|
|
|
5 |
|
|
Additional Information
Acknowledgment
I confirm that I have provided accurate information about the incident and the treatment administered to the best of my knowledge.
Name:
Date:
Incident Report Form Templates @ Template.net
We have received your report!
If you have any additional concerns, please notify us at [Your Company Number].
Create free forms at Template.net
