First Aid Report Form – School Safety Association of BC

First Aid Report

Hidden

OHS Email*

Hidden

Report Date

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*

Incident Time*

:

Date reported*

Time reported*

:

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*

Source*

Primary injury*

Nature of primary injury*

Secondary injury (if applicable)

Nature of secondary injury (if applicable)*

Additional injury information*

List any other injuries and describe all injuries observed

Description of treatment given*

Treatment Date*

Arrangements made for worker*

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*

Upload photos or additional documents

Drop files here or

Max. file size: 4 MB.

First Aid Attendant Report Form

First Aid Report