First Aid Report Form First Aid Attendant Report Form ONLY A CERTIFIED FIRST AID ATTENDANT CAN COMPLETE THIS FORM First Aid ReportHiddenOHS Email* HiddenReport Date MM slash DD slash YYYY School DistrictSchool District 5 Southeast KootenaySchool District 6 Rocky MountainSchool District 8 Kootenay LakeSchool District 10 Arrow LakesSchool District 19 RevelstokeSchool District 20 Kootenay-ColumbiaSchool District 22 VernonSchool District 23 Central OkanaganSchool District 27 Cariboo-ChilcotinSchool District 28 QuesnelSchool District 33 ChilliwackSchool District 34 AbbotsfordSchool District 35 LangleySchool District 36 SurreySchool District 37 DeltaSchool District 38 RichmondSchool District 39 VancouverSchool District 40 New WestminsterSchool District 41 BurnabySchool District 42 Maple Ridge-Pitt MeadowsSchool District 43 CoquitlamSchool District 44 North VancouverSchool District 45 West VancouverSchool District 46 Sunshine CoastSchool District 47 Powell RiverSchool District 48 Sea to SkySchool District 49 Central CoastSchool District 50 Haida GwaiiSchool District 51 BoundarySchool District 52 Prince RupertSchool District 53 Okanagan SimilkameenSchool District 54 Bulkley ValleySchool District 57 Prince GeorgeSchool District 58 Nicola-SimilkameenSchool District 59 Peace River SouthSchool District 60 Peace River NorthSchool District 61 Greater VictoriaSchool District 62 SookeSchool District 63 SaanichSchool District 64 Gulf IslandsSchool District 67 Okanagan SkahaSchool District 68 Nanaimo-LadysmithSchool District 69 QualicumSchool District 70 AlberniSchool District 71 Comox ValleySchool District 72 Campbell RiverSchool District 73 Kamloops/ThompsonSchool District 74 Gold TrailSchool District 75 MissionSchool District 78 Fraser-CascadeSchool District 79 Cowichan ValleySchool District 81 Fort NelsonSchool District 82 Coast MountainsSchool District 83 North Okanagan-ShuswapSchool District 84 Vancouver Island WestSchool District 85 Vancouver Island NorthSchool District 87 StikineSchool District 91 Nechako LakesSchool District 92 Nisga'aSchool District 93 Conseil scolaire francophoneOtherInjured Employee First Name* Injured Employee Last Name* Employee Number*Injured Employee Email* Incident Location*Admiral Seymour ElementaryBayview Community ElementaryBritannia Community ElementaryBritannia Community SecondaryCaptain James Cook ElementaryCarnarvon Community ElementaryChamplain Heights AnnexChamplain Heights Community ElementaryCharles Dickens AnnexCharles Dickens ElementaryChief Maquinna ElementaryCollingwood Neighbourhood ElementaryCrosstown ElementaryDavid Livingstone ElementaryDavid Lloyd George ElementaryDavid Oppenheimer ElementaryDavid Thompson SecondaryDr A R Lord ElementaryDr Annie B Jamieson ElementaryDr George M Weir ElementaryDr H N MacCorkindale ElementaryDr R E McKechnie ElementaryEcole Jules Quesnel ElementaryEcole Laura Secord ElementaryEdith Cavell ElementaryElsie Roy ElementaryEmily Carr ElementaryEric Hamber SecondaryFalse Creek ElementaryFlorence Nightingale ElementaryG T Cunningham ElementaryGathering Place Education CentreGeneral Brock ElementaryGeneral Gordon ElementaryGeneral Wolfe ElementaryGladstone SecondaryGraham Bruce ElementaryGrandview ElementaryHastings Community ElementaryHenry Hudson ElementaryJ W Sexsmith ElementaryJohn Henderson ElementaryJohn Norquay ElementaryJohn Oliver SecondaryKerrisdale AnnexKerrisdale ElementaryKillarney SecondaryKing George SecondaryKitsilano SecondaryL'Ecole Bilingue ElementaryLord Beaconsfield ElementaryLord Byng SecondaryLord Kitchener ElementaryLord Nelson ElementaryLord Roberts AnnexLord Roberts ElementaryLord Selkirk AnnexLord Selkirk ElementaryLord Strathcona ElementaryLord Tennyson ElementaryMagee SecondaryMaple Grove ElementaryMount Pleasant ElementaryNootka Community ElementaryNorma Rose Point SchoolPierre Elliott Trudeau ElementaryPoint Grey SecondaryPrince of Wales SecondaryQueen Alexandra ElementaryQueen Elizabeth AnnexQueen Elizabeth ElementaryQueen Mary ElementaryQueen Victoria AnnexQuilchena ElementaryRenfrew Community ElementaryShaughnessy ElementarySimon Fraser ElementarySir Alexander Mackenzie ElementarySir Charles Kingsford-Smith ElementarySir Charles Tupper SecondarySir Guy Carleton Comm ElementarySir James Douglas AnnexSir James Douglas ElementarySir John Franklin ElementarySir Matthew Begbie ElementarySir Richard McBride AnnexSir Richard McBride ElementarySir Sandford Fleming ElementarySir Wilfred Grenfell ElementarySir Wilfrid Laurier ElementarySir William Osler ElementarySir William Van Horne ElementarySir Winston Churchill SecondarySouth Hill Education CentreSouthlands ElementaryTecumseh AnnexTecumseh ElementaryTempleton SecondaryThunderbird ElementaryTillicum Community AnnexTrafalgar ElementaryTyee ElementaryUniversity Hill ElementaryUniversity Hill SecondaryVancouver Learn Network ElementaryVancouver Learn Network SecondaryVancouver Technical SecondaryWalter Moberly ElementaryWaverley ElementaryWindermere Community SecondaryXpey' ElementaryPosition*Aboriginal Support WorkerAccountingAccounts Payable TechnicianAccounts Receivable TechnicianAdmin AssistantAssistant Secretary-TreasurerAssistant SuperintendentAutism Support WorkerBudget OfficerBus DriverBus MonitorBusiness Systems TechnicianBuyerCabinetmakerCafeteria AssistantCareer AdvisorCareer Advisory AssistantCarpenterChief Financial OfficerChild Care WorkerClericalCoordinatorCounselorCrosswalk SupervisorCustodianCustodian ForemanDepartment HeadDirectorDispatcherDistrict PrincipalDistrict Teacher AllowanceDistrict Vice PrincipalDrug & Alcohol WorkerElectricianEnergy SpecialistEquipment OperatorExec Asst – SuperintendentExec Director- Lsd FoundationExec. Asst To Secretary TreasExecutive AssistantFamily Support WorkerForeman ElectricianForeman Hvac MechanicForeman MechanicForeman PainterForeman Plumber GasfitterForeman CarpenterForeman GroundsForeman Trades CertifiedGlazierGroundskeeperHomestay CoordinatorHomestay OfficerHr OfficerHuman Resources CoordinatorHvac MechanicInstructorIt Support TechnicianKitchen SupervisorLabourerLibrary AssistantLibrary TechnicianLocksmithMail Services AssistantManager – Technical ServicesManager, CommunicationsManager, Swis ProgramManager, Trans,GroundsManager-Accounting & ReportingManager-Building TradesManager-Energy,Envir.& Sp ProjManager-Facilities ServicesManager-Health & SafetyManager-Health & WellnessManager-Human ResourcesManager-Maint/MechanicalManager-Pay/Benefits,PersonnelManager-Purchasing & LogisticsMarketing CoordinatorMarketing Manager-IspMechanicMgr-Capital & Financial PlngMgr-Cust.Serv/Health & SafetyMgr-Planning & Financial CtrlNoon SupervisorOccupational TherapistOffice AssistantPainterPayroll SupervisorPayroll TechnicianPersonnel AssistantPhysiotherapistPlumberPlumber GasfitterPrincipalPrint Services TechnicianProfessional Dev ClerkProgrammerPsychologistPurchasing AssistantPurchasing SupervisorReceiver WarehousemanReceptionistRecords Information OfficerRecreation Program LeaderRegistration OfficerResearch AssistantResource Center AssistantRooferRoute DriverSchool Board TrusteeScience TechnicianSEASecretary TreasurerSenior Manager Human ResourcesSenior Systems EngineerService TechnicianSettlement WorkerSettlement Worker CoordinatorSpeech Language PathologistStrong Start FacilitatorStudent Helper/ShopperStudent Summer ApprenticeSummer Session TeacherSuperintendent Of SchoolsSupervisorTeacherTeacher AssistantTech Support SpecialistTechnicianUtility PersonVice PrincipalWarehousemanYouth Care WorkerOtherType 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 AM/PM Date reported* MM slash DD slash YYYY Time reported* : Hours Minutes AM PM 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*abdomen – upperabdomen – lowerabdomen – midankle- leftankle- rightarm- leftarm- rightback – leftback – upperback – rightback – lowerback – midbuttockschestear- leftear- rightelbow- leftelbow- righteye- lefteye- rightfacefinger- leftfinger- rightfoot- leftfoot- rightgroin- leftgroin- righthand- lefthand- rightheadhip- lefthip- rightknee- leftknee- rightleg- leftleg- rightmouthneck- leftneck- rightno physical injurynoseothershoulder- leftshoulder- rightteethtoe- lefttoe- rightwrist- leftwrist- rightNature 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)abdomen – upperabdomen – lowerabdomen – midankle- leftankle- rightarm- leftarm- rightback – leftback – upperback – rightback – lowerback – midbuttockschestear- leftear- rightelbow- leftelbow- righteye- lefteye- rightfacefinger- leftfinger- rightfoot- leftfoot- rightgroin- leftgroin- righthand- lefthand- rightheadhip- lefthip- rightknee- leftknee- rightleg- leftleg- rightmouthneck- leftneck- rightno physical injurynoseothershoulder- leftshoulder- rightteethtoe- lefttoe- rightwrist- leftwrist- rightNature 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 observedDescription 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* Upload photos or additional documents Drop files here or Select files Max. file size: 64 MB.
