INCIDENT, INJURY, TRAUMA AND ILLNESS RECORD FORM

Treatment Details
First Aid Provided
Ice Pack
Wound cleaned
Dressing applied
Bandage applied
Auto-injector
Inhaler/Puffer
CPR/AED
Splint
Spinal/Neck Collar
Ambulance Called

Pulse Rate:

Time Taken:

Temperature: .

Time Taken:

Other;

Notification of Incident, Injury, Trauma or Illness

Name of Person
Who
Notified
Ambulance Called
written
Verbal
Supervisor / Manager
Written
Verbal
Organisation(s) Notified i.e.
Health Dept./ Work Safe /Other
Written

Verbal

Notifier Name

Signature

Signatures
First Aid Provider
First Aid Qualified
Manager/ Supervisor

Signature
Yes

No Qualification
Signature

Time and Date

Notification Given

INCIDENT, INJURY, TRAUMA AND ILLNESS RECORD FORM

Treatment Details
First Aid Provided
Ice Pack
Wound cleaned
Dressing applied
Bandage applied
Auto-injector
Inhaler/Puffer
CPR/AED
Splint
Spinal/Neck Collar
Ambulance Called

Pulse Rate:

Time Taken:

Temperature: .

Time Taken:

Other;

Notification of Incident, Injury, Trauma or Illness

Name of Person
Who
Notified
Ambulance Called
written
Verbal
Supervisor / Manager
Written
Verbal
Organisation(s) Notified i.e.
Health Dept./ Work Safe /Other
Written

Verbal

Notifier Name

Signature

Signatures
First Aid Provider
First Aid Qualified
Manager/ Supervisor

Signature
Yes

No Qualification
Signature

Time and Date

Notification Given

INCIDENT, INJURY, TRAUMA AND ILLNESS RECORD FORM

Workplace Name
Casualty Name
Date of Birth

Age
Gender

Work Area

Incident, Injury, Trauma or Illness Details

Location
Date
Time
Witnesses
Please mark injuries on body diagram below

Injury Type:
Cut/Laceration
Bruise
Swelling
Bite/Sting
Fracture
Sprain/Strain
Unconscious / Altered
Consciousness
Other:
Cause:
Slip / Trip / Fall
Hazard / Environmental
Equipment
Previous injury / illness
Other:

INCIDENT/INJURY/TRAUMA: Brief description of circumstances leading

to the incident/injury/trauma:
ILLNESS: Brief description of relevant circumstances surrounding the illness
and symptoms:

INCIDENT, INJURY, TRAUMA AND ILLNESS RECORD FORM

Workplace Name
Casualty Name
Date of Birth

Age
Gender

Work Area

Incident, Injury, Trauma or Illness Details

Location
Date
Time
Witnesses
Please mark injuries on body diagram below

Injury Type:
Cut/Laceration
Bruise
Swelling
Bite/Sting
Fracture
Sprain/Strain
Unconscious / Altered
Consciousness
Other:
Cause:
Slip / Trip / Fall
Hazard / Environmental
Equipment
Previous injury / illness
Other:

INCIDENT/INJURY/TRAUMA: Brief description of circumstances leading

to the incident/injury/trauma:
ILLNESS: Brief description of relevant circumstances surrounding the illness
and symptoms: