First Aid Treatment Record

This form must be completed whenever first aid is administered.

Name(Required)

First Last

Occupation

Department

Date of accident/incident(Required)

Time of accident/incident

Place of accident/incident

Nature of injuries(Required)

Has the worker been advised to consult a physician if his condition deteriorates?

Yes

Affected Body Parts

Witnesses Names and Contact information

First Aid Administered:

On Site

Hospital or Medical Clinic

Description

Safety Committee/Representative Comments

Corrective Measures

Injured worker(Required)

First Last

First aider(Required)

First Last

Supervisor/Manager

First Last

Safety Committee/Representative

First Last

Date(Required)

Signature(Required)