"First Aid Record Template - Worksafebc"

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First Aid Record
RESET
This record must be kept by the employer for three (3) years. This form
Sequence number
must be kept at the employer’s workplace. Do NOT submit to WorkSafeBC.
Name
Occupation
Date of injury or illness
Time of injury or illness
(yyyy-mm-dd)
(hh:mm)
a.m.
p.m.
Initial reporting date and time
Follow-up report date and time
(yyyy-mm-dd) (hh:mm)
(yyyy-mm-dd) (hh:mm)
a.m.
p.m.
a.m.
p.m.
Initial report sequence number
Subsequent report sequence number(s)
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 treatment given
(What did you do?)
Name of witnesses
1.
2.
Arrangement made relating to the worker
(return to work/medical aid/ambulance/follow-up)
Yes
No
A form to assist in return to work and follow-up
Provided worker handout
Yes
No
was sent with the worker to medical aid
Alternate duty options were discussed
Yes
No
First aid attendant’s name
First aid attendant’s signature
(please print)
Patient’s signature
Page 1 of 1 (R15/05)
55B23
First Aid Record
RESET
This record must be kept by the employer for three (3) years. This form
Sequence number
must be kept at the employer’s workplace. Do NOT submit to WorkSafeBC.
Name
Occupation
Date of injury or illness
Time of injury or illness
(yyyy-mm-dd)
(hh:mm)
a.m.
p.m.
Initial reporting date and time
Follow-up report date and time
(yyyy-mm-dd) (hh:mm)
(yyyy-mm-dd) (hh:mm)
a.m.
p.m.
a.m.
p.m.
Initial report sequence number
Subsequent report sequence number(s)
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 treatment given
(What did you do?)
Name of witnesses
1.
2.
Arrangement made relating to the worker
(return to work/medical aid/ambulance/follow-up)
Yes
No
A form to assist in return to work and follow-up
Provided worker handout
Yes
No
was sent with the worker to medical aid
Alternate duty options were discussed
Yes
No
First aid attendant’s name
First aid attendant’s signature
(please print)
Patient’s signature
Page 1 of 1 (R15/05)
55B23