FIRST AID INCIDENT REPORT FORM

DATE OF THE INJURY*

TIME OF THE INJURY*

INJURED PERSON'S FULL NAME*

JOB TITLE*

Write Student if the injured person is only a Student of AC.

GENDER*

Male

Female

INJURED PERSON'S PHONE NUMBER*

INJURED PERSON'S RESIDENTIAL ADDRESS*

PERSON MAKING THE REPORT*

AGE OF THE INJURED PERSON*

LOCATION OR SITE WHERE THE PERSON WAS INJURED*

NATURE OF THE INJURY*

CHRONOLOGY OF EVENTS LEADING UP TO THE INJURY*

DETAILS OF ANY WITNESSES*

Write N/A if there were no witnesses

CAUSE OF THE INJURY*

INJURY SEVERITY SCORE*

Select or enter value

LOCATION OF THE INJURY ON THE PERSON'S BODY*

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DESCRIPTION OF THE INJURY*

FIRST AID TREATMENT

DETAILS OF FIRST AID TREATMENT PROVIDED*

Write N/A if no First Aid was needed

ACTION TAKEN BY AC*

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