First Aid Record | School District 63

Name of First Aid Attendant: *

Please enter your full name.

First Aid Attendant Certification Level & Expiry Date: *

Name of Injured Employee: *

School/Location: *

Date: *

Time: *

:

am

pm

Initial Reporting Date: *

Initial Reporting Time: *

:

am

pm

Occupation of injured employee: *

Follow-up Report Date: *

Follow-up Report Time: *

:

am

pm

Subsequent Report Sequence:

Description of how the injury, exposure, or illness occurred (What happened?): *

Description of how the injury, exposure, or illness occurred (What happened?)

Description of the nature of the injury, exposure, or illness (What you see – signs and symptoms): *

Description of the nature of the injury, exposure, or illness (What you see – signs and symptoms)

Description of the Treatment Given (What did you do?): *

Description of the Treatment Given (What did you do?)

Witness Name #1:

Witness Name #2:

Arrangements Made:

Arrangements Made Relating to Worker (return to work/medical aid/ambulance/follow-up)

Provided worker handout: *

Yes

No

Alternative duty options were discusses: *

Yes

No

A form to assist in return to work and follow-up was sent with the worker to medical aid: *

Yes

NO