First Aid Report Form

First Aid Attendant Report Form

ONLY A CERTIFIED FIRST AID ATTENDANT CAN COMPLETE THIS FORM

First Aid Report
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OHS Email*
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Report Date
MM slash DD slash YYYY
School District
Injured Employee First Name*
Injured Employee Last Name*
Employee Number*
Injured Employee Email*
Incident Location*
Position*
Type of incident*
- Workplace Accident
- Reportable Behaviour
- Violent Incident-Student Related
- Violent Incident-Non Student Related
Injury details*
- An injury
- An occupational disease
- A repetitive motion/gradual onset injury
Incident Date or Exposure Start Date*
MM slash DD slash YYYY
Incident Time*

: Hours

Minutes

AM/PM
Date reported*
MM slash DD slash YYYY
Time reported*

: Hours

Minutes

AM/PM
Injury reported to
First Last Title/Position
Detailed description of location of incident (ie: gym, soccer field, etc.)*
Detailed description of the incident*
Witness 1
Name Position/Relation Contact info
Witness 2
Name Position/Relation Contact info
Cause*
- animal, insect bites
- bite, human
- bending, stooping
- caught in, under, between
- contact with
- crushed by
- exposure
- jump – same level
- jump – to lower level
- jump – to upper level
- MVA
- overexertion – carrying
- overexertion – lifting
- overexertion – pulling
- overexertion – pushing
- overexertion – reaching
- overexertion – throwing
- repetitive motion
- running
- slip or trip – did not fall
- slip, trip, fall – different level
- slip, trip, fall – same level
- struck against
- struck by
- twisting
- violence
Source*
- animal
- asbestos
- bee,wasp, hornet
- biological agent
- boxes, crates
- cabinets
- chemical
- cold
- dust
- electrical
- falling object
- flying object
- fumes
- furniture
- garbage bin
- heat
- human
- ice, snow
- ladder
- machine, tool or equipment
- moving part
- noise
- stairs
- step stool
- student
- typing, keying
- wet surfaces
Primary injury*
Nature of primary injury*
- abrasion
- amputation
- bruise
- burn, scald
- concussion
- cut/laceration
- dislocation
- electrical shock
- fracture
- gradual onset
- inflammation
- open wound
- psychological
- puncture
- respiratory disorder
- sprain
- strain
Secondary injury (if applicable)
Nature of secondary injury (if applicable)*
- abrasion
- amputation
- bruise
- burn, scald
- concussion
- cut/laceration
- dislocation
- electrical shock
- fracture
- gradual onset
- inflammation
- open wound
- psychological
- puncture
- respiratory disorder
- sprain
- strain
Additional injury information*
List any other injuries and describe all injuries observed
Description of treatment given*
Treatment Date*
MM slash DD slash YYYY
Arrangements made for worker*
- Returned to work
- Sent for medical attention
- Ambulance called
- Recommended follow-up
- Other
If other, explain:*
Will employee be seeking medical attention?*
- Yes
- No
Will employee be missing any time from work BEYOND day of injury?*
This does not include time missed form work to attend medical appointments and or treatment
- Yes
- No
Is the employee able to perform their regular job duties?*
- Yes
- No
Describe any limitations and/or restrictions*
First Aid Attendant Name*
First Last
Your Email*
ENTER FIRST AID ATTENDANT’S EMAIL
Admin/Manager Safety Rep Email*
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