First Aid Record Sequence # Initial report sequence # Subsequent report sequence #(s) Name Occupation Date & time of injury or illness Time of injury or illness 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM Initial reporting date & time Initial reporting time 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM Follow-up report date & time Follow-up report time 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM What happened? Description of how the injury, exposure, or illness occurred What did you see — signs and symptoms? Description of the nature of the injury, exposure, or illness What did you do? Description of the treatment given Name of witness #1 Name of witness #2 Arrangement made relating to the worker Return to work / medical aid / ambulance / follow-up Provided worker handout No Yes Alternate duty options were discussed No Yes A form to assist in return to work and follow-up was sent with the worker to medical aid * No Yes First aid attendant’s name Form completed by * Captcha If you are human, leave this field blank.
