LO S ANG E LE S CO MMUNI TY CO LLE G E DI S TRI CT

DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT

SUSTAINABLE BUILDING PROGRAM

FIRST AID REGISTER

Contractor:       Project Name:       College:      

Month/Year:       /       Project Number:       College Project Director:      

Incident Report
Type of Injury / Body Part Affected
Date/Time Name Supervisor (Form CPS-0420) Classification**
& Brief Description of Incident
Complete?
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      
                        YES NO      

Classification**: FAV – First Aid Visit E-1 – Doctor’s Visit Cal/OSHA – Cal/OSHA Recordable Other: Specify

CPS-0425 Page 1 of 1 Revised 03/16/2015