Appendix A: Sample First Aid Record Form
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1Appendix A: Sample First Aid Record Form
First Aid Record (Sample)
Date of injury or illness:
Time:
AM
Day
Month
Year
PM
Date injury or illness
Reported to First Aider:
Time:
AM
Day
Month
Year
PM
Full name of injured or ill worker:
Description of the injury or illness:
Description of where the injury or illness occurred/began:
Cause of the injury or illness:
First aid provided? Yes
(If yes, complete the rest of this page) No
Name of first aider:
First aid qualifications:
Emergency First Aider
Emergency Medical Technician- Paramedic
Standard First Aider
Emergency Medical Technician – Ambulance
Advanced First Aider
Emergency Medical Technician
Registered Nurse
Emergency Medical Responder
First Aid provided:
CONFIDENTIAL
Keep this record for at least 3 years from the date of injury or illness
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