"First Aid Incident Report Template - Limestone District School Board"

ADVERTISEMENT
ADVERTISEMENT

Download "First Aid Incident Report Template - Limestone District School Board"

Download PDF

Fill PDF online

Rate (4.6 / 5) 14 votes
FIRST AID INCIDENT REPORT
FORM 140-C
_________________________________________________________________________________
FIRST AID INCIDENT REPORT
DATE: ________________TIME: __________
Ambulance Requested:
Y N
CASUALTIES NAME: _____________________________
OVER 18? Y N
MEDICAL ALERT BRACELET? Y N
DETAILS: ______________________
EMERGENCY CONTACT: _____________________ PHONE #: ______________
NATURE OF INCIDENT OR INJURY:
CASUALTIES HISTORY:
WHAT HAPPENED?
HOW DO YOU FEEL?
DO YOU FEEL PAIN?
WHERE?
WHAT DOES IT FEEL LIKE?
DO YOU HAVE ALLERGIES?
ARE YOU ON MEDICATION?
DO YOU HAVE A MEDICAL CONDITION?
HAS THIS HAPPENED BEFORE?
NOTE:
BREATHING
PULSE
RESPONSIVENESS
PUPILS
ODOUR
LONG TERM HISTORY:
HAVE YOU EATEN TODAY?
WHAT DID YOU EAT LAST NIGHT?
HAVE YOU SLEPT?
HOW DID YOU FEEL EARLIER?
WHAT WERE THE SYMPTOMS?
HOW DID YOU TREAT YOURSELF?
PHYSICAL ACTIVITY TODAY?
EMOTIONAL STATE (STRESS)?
FIRST AID INCIDENT REPORT
FORM 140-C
_________________________________________________________________________________
FIRST AID INCIDENT REPORT
DATE: ________________TIME: __________
Ambulance Requested:
Y N
CASUALTIES NAME: _____________________________
OVER 18? Y N
MEDICAL ALERT BRACELET? Y N
DETAILS: ______________________
EMERGENCY CONTACT: _____________________ PHONE #: ______________
NATURE OF INCIDENT OR INJURY:
CASUALTIES HISTORY:
WHAT HAPPENED?
HOW DO YOU FEEL?
DO YOU FEEL PAIN?
WHERE?
WHAT DOES IT FEEL LIKE?
DO YOU HAVE ALLERGIES?
ARE YOU ON MEDICATION?
DO YOU HAVE A MEDICAL CONDITION?
HAS THIS HAPPENED BEFORE?
NOTE:
BREATHING
PULSE
RESPONSIVENESS
PUPILS
ODOUR
LONG TERM HISTORY:
HAVE YOU EATEN TODAY?
WHAT DID YOU EAT LAST NIGHT?
HAVE YOU SLEPT?
HOW DID YOU FEEL EARLIER?
WHAT WERE THE SYMPTOMS?
HOW DID YOU TREAT YOURSELF?
PHYSICAL ACTIVITY TODAY?
EMOTIONAL STATE (STRESS)?
FIRST AID INCIDENT REPORT
FORM 140-C
_________________________________________________________________________________
RESPONSE TEAM MEMBERS IN ATTENDANCE:
WHAT TREATMENT WAS GIVEN?
WHERE WAS THE CASUALTY FOUND/MOVED?
RECOMMENDATION FOR CASUALTY:
SEE A DOCTOR?
GO HOME?
REST?
FOLLOW UP REQUIRED? Y
N
DETAILS OF FOLLOW UP AND PERSON INVOLVED
RESPONSE TEAM RECOMMENDATIONS:
Page of 2