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First Aid Record Form: Personal Details

This first aid record form contains sections to document the details of an incident requiring first aid treatment, including the personal details of the injured person, description of the incident and injury, first aid treatment provided, and outcome. The form also includes fields to indicate if the incident was investigated and what corrective actions were taken by the manager to prevent future occurrences.

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puput utomo
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4K views1 page

First Aid Record Form: Personal Details

This first aid record form contains sections to document the details of an incident requiring first aid treatment, including the personal details of the injured person, description of the incident and injury, first aid treatment provided, and outcome. The form also includes fields to indicate if the incident was investigated and what corrective actions were taken by the manager to prevent future occurrences.

Uploaded by

puput utomo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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FIRST AID RECORD FORM

PERSONAL DETAILS:

Name:..................................................................... Address:..............................………….............................

Employer:................................................................ Occupation.…....................................……………..........

Known Illness including medications:.......................……………...........................D.O.B........../............./.........

INCIDENT/ACCIDENT DETAILS: INJURY/ILLNESS DETAILS:


Date/time:.............................................………......…. .............................................................................……..
Location:........................................................………. ..............................................................................…….
Work process being performed:.....…….......………..
.......................................................................………. INCIDENT OUTCOME:
Description of incident/accident:...................………. Class I  Class II  Class III 
………………………………………………………. Causes: ..................................................................……
………………………………………………………. …………………………………………………………

FIRST AID TREATMENT:


.......…............................................………................

.................................................................………......

Date:....../....../......
__________________________________________

ACTION: Back to Work 


Hospital 
Doctor/Clinic 
Reported to Supervisor 
Incident Report Required 
(INDICATE LOCATION OF INJURY)

Name:...........................................................……... MANAGER'S COMMENT:


(print name of person completing this form) Yes No
Has incident been investigated?  
Address:.........................................................…….
(please print) Has Corrective Action been
.......................................................................……. implemented?  

Site Address: ……………………………….……. Has incident investigation report


……………………………………………………. been completed?  

..............................……………. ..................................................... ......................


(Signature) Signature Date

To be completed for all first aid treatments. Original forwarded to the SHE Coordinator at the end of each month.

PT. Cipta Kridatama Page 1 of 1

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